ISO 27001:2022 clause 5.1 Leadership and Commitment

Top management shall demonstrate leadership and commitment with respect to the information security management system by:

  • ensuring the information security policy and the information security objectives are established and are compatible with the strategic direction of the organization;
  • ensuring the integration of the information security management system requirements into the organization’s processes;
  • ensuring that the resources needed for the information security management system are available;
  • communicating the importance of effective information security management and of conforming to the information security management system requirements;
  • ensuring that the information security management system achieves its intended outcome ;
  • directing and supporting persons to contribute to the effectiveness of the information security management system;
  • promoting continual improvement; and
  • supporting other relevant management roles to demonstrate their leadership as it applies to their areas of responsibility.

NOTE Reference to “business” in this document can be interpreted broadly to mean those activities that are core to the purposes of the organization’s existence.

Top management shall demonstrate leadership and commitment with respect to the information security management system

Demonstrating leadership and commitment from top management is crucial for the successful implementation and maintenance of an effective Information Security Management System (ISMS).This clause identifies specific aspects of the management system where top management are expected to demonstrate both leadership and commitment. These include but are not limited to:

  • Accountability for the effectiveness of the management system;
  • Ensuring the policy and objectives are established and are compatible with the context and strategic direction of the organisation;
  • Ensuring the integration of the management system are embedded into business processes;
  • Promoting the use of the process approach and risk-based thinking
  • Ensuring adequate resources are in place;
  • Ensuring the management system achieves its intended results;
  • Engaging, directing and supporting persons to contribute to the effectiveness of the management system

Here are some key ways in which top management can show leadership and commitment in this context:

  1. Policy Development: Top management must Create an Information Security Policy. Top management should take the lead in developing a comprehensive information security policy that aligns with the organization’s objectives. This policy should set the tone for the entire ISMS.
  2. Resource Allocation: Top management must allocate Adequate Resources. Ensure that sufficient resources, including budget, personnel, and technology, are allocated to implement and maintain the ISMS effectively.
  3. Communication: Top management must ensure communication of Objectives. Clearly communicate the importance of information security and the objectives of the ISMS to all employees. Regularly reinforce this message to ensure awareness and understanding throughout the organization.
  4. Leading by Example: Top management must ensure adherence to Policies. Top management should lead by example by adhering to the information security policies and procedures. This creates a culture of compliance throughout the organization.
  5. Training and Awareness: Top management must support Training Programs. It must provide support for ongoing training and awareness programs related to information security. This helps employees understand their roles and responsibilities in maintaining the security of information assets.
  6. Risk Management: Top management must ensure active Involvement in Risk Management. Top management should actively participate in risk assessments and risk management processes to ensure that the organization is identifying and addressing potential threats and vulnerabilities.
  7. Monitoring and Review: Top management must regular Review of ISMS. Conduct regular reviews and assessments of the ISMS to ensure its effectiveness. This includes reviewing security controls, incident reports, and the overall performance of the system.
  8. Continuous Improvement: Top management must promote Continuous Improvement. Encourage a culture of continuous improvement by fostering innovation and adapting the ISMS to changing threats and technologies.
  9. Compliance with Standards: Top management must ensure adherence to Standards. Ensure that the ISMS complies with relevant standards and regulations. This demonstrates a commitment to meeting legal and regulatory requirements.
  10. Incident Response: Top management must ensure effective Incident Response. Top management should be involved in the development and testing of incident response plans. In the event of a security incident, their leadership is crucial for a coordinated and effective response.
  11. Integration with Business Processes: Top management must integrate ISMS with Business Processes. Ensure that the ISMS is integrated into the organization’s overall business processes. This alignment helps in embedding security practices into everyday operations.

Demonstrating leadership and commitment at the highest levels of an organization is fundamental to creating a strong and resilient information security culture. It sets the tone for the entire organization and reinforces the importance of safeguarding information assets.

Top management must ensure that the information security policy and the information security objectives are established and are compatible with the strategic direction of the organization.

Aligning the information security policy and objectives with the strategic direction of the organization is crucial for the overall success and effectiveness of the Information Security Management System (ISMS). Here’s why and how top management can ensure this alignment:

Why Alignment is Important:

  1. Support Organizational Goals: Aligning the information security policy with the strategic direction ensures that security measures support, rather than hinder, the achievement of organizational goals.
  2. Resource Allocation: It helps in the proper allocation of resources, ensuring that investments in information security contribute directly to the organization’s strategic priorities.
  3. Risk Management: Ensures that security measures are aligned with the organization’s risk appetite and that potential risks to the achievement of strategic objectives are adequately addressed.
  4. Cultural Integration: Integrating information security into the strategic direction helps to embed a security-conscious culture throughout the organization.

How Top Management Can Ensure Alignment:

  1. Active Involvement: Top management should actively participate in the development of the information security policy, ensuring that it reflects the organization’s strategic priorities.
  2. Regular Review: Periodically review the information security policy and objectives to ensure they remain aligned with the evolving strategic direction of the organization.
  3. Communication: Effectively communicate the importance of information security in achieving the organization’s strategic goals. This helps create awareness and buy-in across all levels of the organization.
  4. Integration with Business Processes: Integrate information security considerations into various business processes, ensuring that security becomes an integral part of day-to-day operations.
  5. Risk Assessment: Conduct regular risk assessments to identify and assess the impact of potential threats on the organization’s strategic objectives. Adjust the information security measures accordingly.
  6. Performance Metrics: Establish performance metrics and key performance indicators (KPIs) that are in line with both information security objectives and broader organizational goals.
  7. Training and Awareness: Provide training and awareness programs that emphasize the relationship between information security and the organization’s strategic success.
  8. Adaptability: Ensure that the information security policy and objectives are adaptable to changes in the business environment, technology landscape, and regulatory requirements.
  9. Leadership by Example: Top management should lead by example, demonstrating through their actions and decisions that information security is a fundamental aspect of the organization’s strategy.
  10. Continuous Improvement: Foster a culture of continuous improvement, where the information security policy is regularly reviewed and updated to address emerging threats and changes in the organizational landscape.

By integrating information security into the strategic planning and decision-making processes, top management ensures that the organization is well-positioned to address security challenges in a way that complements and enhances its overall strategic objectives.

f leadership are not actively involved e.g. don’t participate in management reviews or cannot demonstrate to the external auditor there is a leadership representative taking it seriously during an audit then the organisation will almost certainly fail. Auditors talk about the spirit of ISO 27001 coming from the top and if they don’t see that they will probably look much more deeply and skeptically during the audit.

As has been stated many times before information security management is a business critical philosophy and must be compatible with an organisations business objectives and processes for it to work in practice. Without leadership support, or a requirement to do 25 things before someone actually does the job they want to do, the ISO 27001 journey will struggle to get off the ground. Being able to demonstrate this leadership commitment is essential for clause 5.1, and that’s where a more serious information security management system comes into play that both evidences leadership commitment to investing in an ISMS and having the evidence they have been involved e.g. in management reviews and broader ISMS decision making as well as the required annual external audits for ISO 27001. If a statutory financial accountant saw all the financial accounting just being done with spreadsheets instead of a professional accounting application they might question its integrity and spend longer than if the work was done with any recognized solution. It is the same for information security management. Using the right tools and having the right people involved breeds confidence. Having those foundations in place makes this clause easy to demonstrate and compliance simply requires documented evidence as notes to reinforce that leadership and commitment is in place and addressing clause 5.1 

Top management must ensure of the integration of the information security management system requirements into the organization’s processes.

Integrating the Information Security Management System (ISMS) requirements into the organization’s processes is critical for the effective implementation and sustainability of information security practices. Top management plays a key role in ensuring this integration. Here are some key steps and considerations for top management to ensure the successful integration of ISMS requirements into organizational processes:

  1. Leadership and Advocacy: Top management must demonstrate Leadership. Top management should actively advocate for the integration of ISMS requirements and lead by example in incorporating security considerations into decision-making processes.
  2. Policy Alignment: Top management must align ISMS Policies with Organizational Processes.Ensure that the information security policies are aligned with the organization’s overall policies and objectives. This alignment sets the foundation for integration.
  3. Risk-Based Approach: Top management must implement a Risk-Based Approach. Integrate risk management practices into the organization’s processes, ensuring that security measures are commensurate with the identified risks.
  4. Communication: Top management must communicate Expectations. Clearly communicate to all levels of the organization the expectations regarding the integration of ISMS requirements. This includes emphasizing the importance of information security in daily operations.
  5. Training and Awareness: It must provide Training Programs. Offer training and awareness programs to employees to ensure they understand the ISMS requirements and how these relate to their specific roles and responsibilities.
  6. Process Mapping: It must map ISMS Requirements to Processes. Identify and map ISMS requirements to existing organizational processes. This helps in understanding where security controls need to be implemented.
  7. Embed Security Controls: It must embed Controls into Processes. Integrate security controls seamlessly into existing processes, making them a natural part of day-to-day operations. This minimizes disruptions and resistance to change.
  8. Performance Metrics: It must define Key Performance Indicators (KPIs). Establish performance metrics that measure the effectiveness of security controls integrated into processes. This helps in monitoring and continuous improvement.
  9. Incident Response Integration: It must integrate Incident Response Procedures. Ensure that incident response procedures are integrated into broader organizational incident management processes to facilitate a coordinated and effective response to security incidents.
  10. Regular Audits and Reviews: It must conduct Regular Audits. Implement regular audits and reviews to assess the effectiveness of ISMS integration into processes and identify areas for improvement.
  11. Collaboration with Departments: It must collaborate with Departments. Work closely with different departments to understand their specific needs and challenges, and tailor ISMS integration accordingly.
  12. Adaptability: It must adapt to Changes. Ensure that the ISMS and its requirements are adaptable to changes in technology, business processes, and the overall organizational environment.
  13. Compliance Monitoring: It must monitor Compliance. Regularly monitor and ensure compliance with ISMS requirements, addressing any deviations promptly.

By actively promoting and overseeing the integration of ISMS requirements into organizational processes, top management helps create a culture where information security is an integral and natural part of how the organization operates. This proactive approach enhances the effectiveness of the ISMS and strengthens the overall security posture of the organization.

Top management must ensuring that the resources needed for the information security management system are available.

Ensuring the availability of resources is a critical responsibility for top management in the successful implementation and maintenance of an effective Information Security Management System (ISMS). Here are key considerations and actions that top management should take to fulfill this responsibility:

  1. Resource Assessment: The organization must conduct a Resource Assessment. Identify and assess the resources required for the implementation and maintenance of the ISMS. This includes financial resources, human resources, technology, and any other necessary assets.
  2. Budget Allocation: Allocate Sufficient Budget. Ensure that an adequate budget is allocated to support the implementation and ongoing operation of the ISMS. This budget should cover training, technology infrastructure, security tools, and other related expenses.
  3. Staffing and Skills: Ensure Adequate Staffing. Assess the staffing needs for the ISMS and ensure that there are sufficient personnel with the necessary skills and expertise to carry out information security functions.
  4. Training and Awareness: Invest in Training Programs. Allocate resources for training programs to enhance the skills and awareness of employees regarding information security. This includes training for IT staff, as well as general awareness programs for all employees.
  5. Technology Infrastructure: Invest in Technology. Provide the necessary resources for acquiring and maintaining technological infrastructure that supports information security measures. This includes hardware, software, and security tools.
  6. Third-Party Support: Consider External Support. If needed, consider outsourcing certain aspects of information security or obtaining external expertise to supplement in-house capabilities. Allocate resources for engaging external support, if necessary.
  7. Regular Review: Periodic Resource Review. Regularly review the resource allocation to ensure that it remains sufficient and effective in addressing the evolving needs of the ISMS.
  8. Emergency Response: Allocate Resources for Incident Response. Ensure that resources are allocated specifically for incident response activities, including investigation, mitigation, and recovery efforts in the event of a security incident.
  9. Compliance Monitoring: Allocate Resources for Compliance. Allocate resources to monitor and ensure compliance with relevant regulatory requirements, standards, and internal policies.
  10. Communication and Buy-In: Communicate Resource Needs. Clearly communicate to top management and other relevant stakeholders the resource needs of the ISMS, emphasizing the importance of these resources for the organization’s overall security posture.
  11. Continuous Improvement: Support Continuous Improvement. Encourage a culture of continuous improvement, where resources are continually assessed and adjusted to address emerging threats and changing business environments.
  12. Flexibility and Adaptability: Be Flexible and Adaptive. Recognize that resource needs may change over time, and be prepared to adapt resource allocations based on evolving risks and organizational requirements.

By ensuring the availability of resources for the ISMS, top management sets the foundation for a robust and sustainable information security program. This proactive approach helps in maintaining a strong security posture and effectively mitigating risks to the organization’s information assets.

Top management must communicate the importance of effective information security management and of conforming to the information security management system requirements. Ensuring that the Information Security Management System (ISMS) achieves its intended outcome is a critical responsibility for top management. This involves overseeing the implementation, monitoring, and continuous improvement of the ISMS to effectively protect information assets. Here are key actions and considerations for top management in this regard:

  1. Define Clear Objectives: Set Clear ISMS Objectives. Clearly define the objectives of the ISMS, ensuring they align with the organization’s overall business goals and risk management strategies.
  2. Leadership and Commitment: Demonstrate Leadership. Continuously demonstrate leadership and commitment to information security. This includes visibly supporting the ISMS and its objectives.
  3. Allocate Adequate Resources: Ensure Resource Availability. Provide the necessary resources, including budget, personnel, and technology, to support the effective implementation and maintenance of the ISMS.
  4. Establish Key Performance Indicators (KPIs): Define Performance Metrics. Establish measurable Key Performance Indicators (KPIs) that reflect the effectiveness of the ISMS in achieving its intended outcomes. This may include metrics related to risk reduction, incident response, and compliance.
  5. Regular Performance Evaluation: Conduct Regular Reviews. Periodically review the performance of the ISMS against established KPIs. This allows top management to assess the system’s effectiveness and identify areas for improvement.
  6. Monitoring and Measurement: Implement Monitoring Mechanisms. Put in place mechanisms for ongoing monitoring and measurement of key aspects of the ISMS, such as the effectiveness of security controls and incident response capabilities.
  7. Risk Management: Monitor and Manage Risks: Stay actively involved in the risk management process. Regularly assess and reassess risks to information assets, ensuring that the ISMS adapts to changing threat landscapes.
  8. Regular Audits and Assessments: Conduct Audits and Assessments. Arrange for regular internal and external audits to assess the compliance and effectiveness of the ISMS. Use the findings to drive improvement initiatives.
  9. Review Security Incidents: Analyze Security Incidents. In the event of security incidents, conduct thorough reviews to understand the root causes, assess the effectiveness of incident response measures, and implement corrective actions.
  10. Continuous Improvement: Promote a Culture of Improvement. Foster a culture of continuous improvement within the organization. Encourage feedback and actively seek opportunities to enhance the ISMS.
  11. Document Lessons Learned: Document lessons learned from incidents, audits, and reviews. Apply these lessons to refine processes and enhance the resilience of the ISMS.
  12. Communication and Reporting: Regularly communicate the performance of the ISMS to relevant stakeholders, including executives, board members, and employees. Transparency is crucial for accountability.
  13. Adapt to Organizational Changes: Ensure that the ISMS is adaptable to organizational changes, such as mergers, acquisitions, or changes in business strategies.
  14. Legal and Regulatory Compliance: Stay informed about changes in legal and regulatory requirements. Ensure that the ISMS remains in compliance with relevant standards and regulations.
  15. Employee Awareness: Promote Employee Awareness. Continuously promote awareness among employees regarding their roles and responsibilities in supporting the ISMS objectives.

By actively overseeing these aspects, top management plays a pivotal role in ensuring that the ISMS achieves its intended outcome of safeguarding information assets and mitigating risks. This ongoing commitment contributes to a resilient and effective information security posture within the organization.

Top management must ensure that the information security management system achieves its intended outcome.

Ensuring that the Information Security Management System (ISMS) achieves its intended outcome is a critical responsibility for top management. This involves overseeing the implementation, monitoring, and continuous improvement of the ISMS to effectively protect information assets. Here are key actions and considerations for top management in this regard:

  1. Define Clear Objectives:
    • Set Clear ISMS Objectives: Clearly define the objectives of the ISMS, ensuring they align with the organization’s overall business goals and risk management strategies.
  2. Leadership and Commitment:
    • Demonstrate Leadership: Continuously demonstrate leadership and commitment to information security. This includes visibly supporting the ISMS and its objectives.
  3. Allocate Adequate Resources:
    • Ensure Resource Availability: Provide the necessary resources, including budget, personnel, and technology, to support the effective implementation and maintenance of the ISMS.
  4. Establish Key Performance Indicators (KPIs):
    • Define Performance Metrics: Establish measurable Key Performance Indicators (KPIs) that reflect the effectiveness of the ISMS in achieving its intended outcomes. This may include metrics related to risk reduction, incident response, and compliance.
  5. Regular Performance Evaluation:
    • Conduct Regular Reviews: Periodically review the performance of the ISMS against established KPIs. This allows top management to assess the system’s effectiveness and identify areas for improvement.
  6. Monitoring and Measurement:
    • Implement Monitoring Mechanisms: Put in place mechanisms for ongoing monitoring and measurement of key aspects of the ISMS, such as the effectiveness of security controls and incident response capabilities.
  7. Risk Management:
    • Monitor and Manage Risks: Stay actively involved in the risk management process. Regularly assess and reassess risks to information assets, ensuring that the ISMS adapts to changing threat landscapes.
  8. Regular Audits and Assessments:
    • Conduct Audits and Assessments: Arrange for regular internal and external audits to assess the compliance and effectiveness of the ISMS. Use the findings to drive improvement initiatives.
  9. Review Security Incidents:
    • Analyze Security Incidents: In the event of security incidents, conduct thorough reviews to understand the root causes, assess the effectiveness of incident response measures, and implement corrective actions.
  10. Continuous Improvement:
    • Promote a Culture of Improvement: Foster a culture of continuous improvement within the organization. Encourage feedback and actively seek opportunities to enhance the ISMS.
  11. Document Lessons Learned:
    • Document and Apply Lessons Learned: Document lessons learned from incidents, audits, and reviews. Apply these lessons to refine processes and enhance the resilience of the ISMS.
  12. Communication and Reporting:
    • Communicate ISMS Performance: Regularly communicate the performance of the ISMS to relevant stakeholders, including executives, board members, and employees. Transparency is crucial for accountability.
  13. Adapt to Organizational Changes:
    • Ensure Adaptability: Ensure that the ISMS is adaptable to organizational changes, such as mergers, acquisitions, or changes in business strategies.
  14. Legal and Regulatory Compliance:
    • Monitor Compliance: Stay informed about changes in legal and regulatory requirements. Ensure that the ISMS remains in compliance with relevant standards and regulations.
  15. Employee Awareness:
    • Promote Employee Awareness: Continuously promote awareness among employees regarding their roles and responsibilities in supporting the ISMS objectives.

By actively overseeing these aspects, top management plays a pivotal role in ensuring that the ISMS achieves its intended outcome of safeguarding information assets and mitigating risks. This ongoing commitment contributes to a resilient and effective information security posture within the organization.

Top management must directing and supporting persons to contribute to the effectiveness of the information security management system

Top management plays a crucial role in directing and supporting individuals throughout the organization to contribute effectively to the Information Security Management System (ISMS). Here are key actions and considerations for top management in this regard:

  1. Clear Communication:
    • Articulate Expectations: Clearly communicate the importance of information security and the role each individual plays in supporting the ISMS. Emphasize the organization’s commitment to security.
  2. Establishing a Security Culture:
    • Promote a Security Culture: Foster a culture where information security is considered everyone’s responsibility. This involves creating awareness and instilling a sense of ownership regarding security practices.
  3. Training and Education:
    • Provide Training Programs: Offer regular training programs to enhance the knowledge and skills of employees in information security best practices. This includes awareness training and role-specific security education.
  4. Role-specific Guidance:
    • Provide Role-specific Guidance: Clearly define and communicate the information security responsibilities associated with each role within the organization. Tailor guidance to the specific needs of different departments.
  5. Support for Compliance:
    • Ensure Compliance Support: Provide the necessary support and resources to help individuals understand and comply with information security policies, standards, and procedures.
  6. Resource Allocation:
    • Allocate Adequate Resources: Ensure that individuals have access to the resources and tools needed to fulfill their information security responsibilities. This includes technology, training, and support.
  7. Leadership by Example:
    • Demonstrate Leadership: Top management should lead by example in adhering to information security practices. This helps set the tone for the entire organization and reinforces the importance of security.
  8. Encourage Reporting:
    • Promote Reporting of Security Concerns: Establish channels for employees to report security incidents, concerns, or potential vulnerabilities without fear of reprisal. Encourage a culture of openness and reporting.
  9. Regular Communication:
    • Maintain Open Communication Channels: Keep communication channels open to address questions, concerns, and feedback related to information security. This includes regular updates and town hall meetings.
  10. Recognition and Incentives:
    • Recognize Contributions: Acknowledge and recognize individuals who actively contribute to the effectiveness of the ISMS. Consider incorporating information security achievements into employee recognition programs.
  11. Performance Appraisals:
    • Include Security in Performance Appraisals: Integrate information security performance metrics into individual performance appraisals to emphasize the importance of security responsibilities.
  12. Feedback Mechanisms:
    • Encourage Two-way Feedback: Establish mechanisms for individuals to provide feedback on information security processes, policies, and their effectiveness. Use this feedback for continuous improvement.
  13. Empowerment and Autonomy:
    • Empower Employees: Empower individuals to take ownership of information security in their respective roles. Provide autonomy within established security frameworks.
  14. Regular Audits and Reviews:
    • Participate in Audits and Reviews: Participate in audits and reviews of information security processes to ensure that individuals are following established procedures and that the ISMS is effective.
  15. Continual Improvement:
    • Encourage Continuous Improvement: Encourage a mindset of continuous improvement in information security practices. Individuals should be proactive in identifying and addressing potential security enhancements.

By actively directing and supporting individuals in contributing to the effectiveness of the ISMS, top management helps create a collaborative and security-conscious environment. This approach is essential for building a resilient information security culture within the organization.

Top management must promoting continual improvement.

Promoting continual improvement is a fundamental aspect of effective leadership in any management system, including the Information Security Management System (ISMS). Here are key actions and considerations for top management to promote continual improvement in the context of information security:

  1. Establish a Culture of Continuous Improvement:
    • Promote a Mindset: Foster a culture where continuous improvement is not just encouraged but expected. Emphasize that improvement is an ongoing process, not a one-time initiative.
  2. Set Clear Objectives:
    • Define Improvement Objectives: Clearly define improvement objectives within the ISMS. These objectives should align with the organization’s overall goals and address emerging threats and vulnerabilities.
  3. Performance Monitoring:
    • Regularly Monitor Performance: Implement mechanisms to monitor the performance of the ISMS, including key performance indicators (KPIs). Regularly review these metrics to identify areas for improvement.
  4. Feedback Mechanisms:
    • Encourage Feedback: Establish channels for employees to provide feedback on information security processes, policies, and potential areas for improvement. Encourage an open and constructive feedback culture.
  5. Risk Management and Lessons Learned:
    • Integrate Lessons Learned: Incorporate lessons learned from security incidents, audits, and reviews into the improvement process. Analyze root causes and use insights to enhance security measures.
  6. Regular Audits and Assessments:
    • Conduct Regular Audits: Conduct internal and external audits to assess the effectiveness of the ISMS. Use audit findings to identify weaknesses and opportunities for improvement.
  7. Benchmarking:
    • Benchmark Against Best Practices: Compare the organization’s information security practices against industry best practices and standards. Identify areas where the organization can align itself with or surpass established benchmarks.
  8. Employee Involvement:
    • Involve Employees: Actively involve employees in the improvement process. Encourage them to contribute ideas and suggestions for enhancing information security practices in their respective areas.
  9. Training and Skill Development:
    • Invest in Training Programs: Allocate resources for ongoing training programs to enhance the skills and knowledge of employees in information security. Ensure that employees are well-equipped to address evolving security challenges.
  10. Regular Reviews by Top Management:
    • Periodic Reviews: Conduct periodic reviews of the ISMS at the top management level. Assess the overall effectiveness of security measures and make strategic decisions for continual improvement.
  11. Adaptability to Changing Threat Landscape:
    • Stay Adaptive: Recognize that the threat landscape is dynamic. Ensure that the ISMS is adaptive and responsive to emerging threats. Update security measures as needed to address new risks.
  12. Document and Communicate Improvements:
    • Document Changes: Keep detailed records of improvements made to the ISMS. Communicate these changes to relevant stakeholders to ensure transparency and awareness.
  13. Celebrate Achievements:
    • Acknowledge Success: Acknowledge and celebrate achievements related to information security improvements. Recognizing success boosts morale and reinforces the importance of continual improvement.
  14. Management Review Meetings:
    • Conduct Management Review Meetings: Hold regular management review meetings to discuss the performance of the ISMS, review improvement initiatives, and make strategic decisions to enhance information security.
  15. Commitment to Resources:
    • Allocate Resources for Improvement: Ensure that adequate resources, including budget and personnel, are allocated to support improvement initiatives identified within the ISMS.

By actively promoting continual improvement, top management contributes to the agility and resilience of the organization’s information security posture. This proactive approach helps the organization stay ahead of evolving threats and challenges in the dynamic field of information security.

Top management must supporting other relevant management roles to demonstrate their leadership as it applies to their areas of responsibility

Supporting other relevant management roles in demonstrating leadership is crucial for the overall effectiveness of an organization’s Information Security Management System (ISMS). Top management’s support can empower other leaders to take ownership of information security within their specific areas of responsibility. Here are key actions and considerations for top management to support and promote leadership in various management roles:

  1. Clearly Communicate Expectations:
    • Articulate Information Security Expectations: Clearly communicate to other management roles the expectations regarding information security within their areas of responsibility. Emphasize the importance of their leadership in promoting a secure environment.
  2. Provide Training and Awareness:
    • Offer Specialized Training: Provide specialized training and awareness programs tailored to the roles and responsibilities of different management functions. This ensures that leaders understand their unique contributions to information security.
  3. Define Information Security Roles:
    • Clearly Define Roles and Responsibilities: Clearly define the information security roles and responsibilities of each management position. This includes specifying how they contribute to the overall success of the ISMS.
  4. Resource Allocation:
    • Ensure Adequate Resources: Support other management roles by ensuring they have the necessary resources, including budget, personnel, and technology, to fulfill their information security responsibilities effectively.
  5. Set Information Security Objectives:
    • Collaboratively Set Objectives: Collaborate with other management roles to set specific information security objectives that align with the overall business goals and the ISMS. Encourage leaders to integrate these objectives into their strategic plans.
  6. Integrate Information Security into Processes:
    • Assist in Process Integration: Work with other management roles to integrate information security considerations into their specific business processes. This helps embed security practices into daily operations.
  7. Performance Metrics:
    • Establish Performance Metrics: Collaboratively establish key performance indicators (KPIs) for information security that align with the responsibilities of different management roles. Use these metrics to measure and improve performance.
  8. Regular Reviews and Audits:
    • Participate in Reviews: Actively participate in regular reviews and audits of information security practices within each department or functional area. Provide support in addressing findings and implementing corrective actions.
  9. Promote a Security Culture:
    • Encourage Leadership in Security Culture: Encourage leaders to foster a security-conscious culture within their teams. Promote behaviors that prioritize information security and embed it in the organizational culture.
  10. Recognition and Rewards:
    • Acknowledge Achievements: Recognize and acknowledge the achievements of leaders who demonstrate strong leadership in information security. Consider incorporating security-related goals into performance evaluations and recognition programs.
  11. Encourage Communication Channels:
    • Facilitate Open Communication: Create channels for open communication between top management and other management roles regarding information security matters. Encourage the reporting of concerns and the sharing of best practices.
  12. Continuous Improvement Initiatives:
    • Support Improvement Initiatives: Support other management roles in identifying and implementing continuous improvement initiatives related to information security. Provide guidance and resources for enhancing security measures.
  13. Share Best Practices:
    • Facilitate Knowledge Sharing: Encourage the sharing of information security best practices among different management roles. Foster a collaborative environment where leaders can learn from each other.
  14. Lead by Example:
    • Demonstrate Leadership: Model strong leadership in information security by consistently adhering to security practices and demonstrating a commitment to the organization’s information security objectives.
  15. Regular Coordination Meetings:
    • Hold Coordination Meetings: Conduct regular coordination meetings with leaders from different departments to discuss information security updates, challenges, and strategic initiatives.

By actively supporting and empowering other management roles, top management contributes to a holistic and organization-wide approach to information security. This collaborative effort enhances the overall resilience and effectiveness of the ISMS.

Reference to “business” can be interpreted broadly to mean those activities that are core to the purposes of the organization’s existence.

According to ISO/IEC 27001, the term “business” refers to the activities that an organization undertakes to achieve its intended outcomes. These activities can include a wide range of functions, operations, processes, and services that contribute to the organization’s objectives. The standard recognizes that organizations vary widely in their nature, size, structure, and objectives, and, therefore, the interpretation of “business” is flexible. By interpreting “business” broadly, the ISMS standard acknowledges that the scope of information security management should cover all aspects of an organization’s operations that are essential to its existence and objectives. This includes, but is not limited to:

  1. Core Business Processes: The primary functions or operations that directly contribute to the organization’s products or services.
  2. Supporting Functions: Activities that support and enable the core business processes, such as human resources, finance, IT services, and administration.
  3. Strategic Initiatives: Projects or initiatives that are critical to the organization’s strategic goals and objectives.
  4. Stakeholder Interactions: Interactions with customers, partners, suppliers, and other stakeholders that are integral to the organization’s success.
  5. Legal and Regulatory Compliance: Activities related to compliance with laws, regulations, and contractual obligations that impact the organization’s operations.
  6. Risk Management: Processes for identifying, assessing, and managing risks that could affect the achievement of organizational objectives.

By taking a broad view of “business” in the context of the ISMS, organizations can ensure that their information security efforts are comprehensive and aligned with the entirety of their operations. This approach helps in identifying and mitigating risks across all aspects of the organization, contributing to a more robust and effective information security posture.

Documents required:

  1. Information Security Policy : A documented information that establishes the framework for the ISMS and sets out the organization’s approach to information security.
  2. Scope of the ISMS: A documented statement that defines the scope of the ISMS, outlining the boundaries and applicability of the system.
  3. Information Security Risk Assessment and Treatment Process: A documented procedure or set of documents that describe how the organization conducts risk assessments, assesses risks, and defines risk treatment plans.
  4. Statement of Applicability: A documented information that identifies the controls selected and applied, and the justification for their inclusion based on the risk assessment.
  5. Information Security Objectives: Documented information that specifies the organization’s information security objectives, including details on how they will be achieved.
  6. Roles, Responsibilities, and Authorities: Documents defining the roles, responsibilities, and authorities related to information security, including those of top management and other relevant roles.
  7. Communication Plan: A documented information that outlines the communication processes and responsibilities for internal and external communications related to the ISMS.
  8. Documentation Control Procedure: A documented procedure specifying how documents are approved, reviewed, updated, and made available.

Records required:

  1. Records of Management Reviews : Records of management reviews, including minutes of meetings, decisions, and actions related to the performance and effectiveness of the ISMS.
  2. Records of Training, Awareness, and Competence : Records demonstrating that employees are aware of their information security responsibilities and have received appropriate training.
  3. Records of Risk Assessments and Treatment Plans : Records of risk assessments, including the identification of risks, assessment of their impact and likelihood, and the development of treatment plans.
  4. Records of Security Incidents :Records documenting information security incidents, including their nature, impact, and corrective actions taken.
  5. Records of Corrective Actions :Records documenting corrective actions taken in response to incidents, non conformities, or the results of audits and reviews.
  6. Records of Monitoring and Measurement Results :Records of monitoring and measurement activities related to information security performance, including the results of internal audits and evaluations.
  7. Records of External Communications :Records of external communications related to information security, including communications with interested parties.

ISO 27001:2022 Clause 4.4 Information security management system


The organization shall establish, implement, maintain and continually improve an information security management system, including the processes needed and their interactions, in accordance with the requirements of this document.

Establishing an Information Security Management System (ISMS) involves a systematic and structured approach to ensure the confidentiality, integrity, and availability of an organization’s information assets. Below are the key steps to guide an organization in establishing an ISMS:

1. Leadership and Commitment:

  • Appoint a Management Representative: Designate an individual or team responsible for coordinating the development and implementation of the ISMS.
  • Top Management Commitment: Gain commitment from top management to support and actively participate in the establishment of the ISMS.

2. Define the Scope:

  • Identify Organizational Boundaries: Determine the organizational units, functions, and processes that will be included within the scope of the ISMS.
  • Consider External and Internal Context: Analyze external and internal issues, interested parties, and interfaces with other organizations to define the ISMS scope comprehensively.

3. Perform a Risk Assessment:

  • Identify Information Assets: Identify and classify information assets based on their value and importance to the organization.
  • Identify Threats and Vulnerabilities: Conduct a risk assessment to identify potential threats and vulnerabilities that could impact information assets.
  • Assess Risks: Assess the likelihood and impact of identified risks to prioritize and focus on significant risks.

4. Define Information Security Objectives:

  • Align with Business Objectives: Define information security objectives that align with the organization’s overall business objectives.
  • Establish Measurable Targets: Set measurable targets for achieving information security objectives. Ensure that targets are specific, measurable, achievable, relevant, and time-bound (SMART).

5. Implement Information Security Controls:

  • Select Controls: Identify and select appropriate information security controls based on the risk assessment and organizational objectives.
  • Documentation and Procedures: Develop documentation and procedures to implement the selected controls effectively.
  • Training and Awareness: Provide training and awareness programs to ensure that employees understand their roles and responsibilities in maintaining information security.

6. Documentation and Records:

  • ISMS Documentation: Develop documented information that outlines the ISMS scope, policies, procedures, and risk assessment outcomes.
  • Records Management: Establish a system for creating, maintaining, and retaining records related to information security.

7. Monitoring and Measurement:

  • Performance Monitoring: Implement processes to monitor and measure the performance of information security controls and the effectiveness of the ISMS.
  • Incident Response: Establish an incident response plan to address and mitigate the impact of security incidents.

8. Internal Audits:

  • Conduct Internal Audits: Periodically conduct internal audits to assess the compliance and effectiveness of the ISMS.
  • Corrective Actions: Implement corrective actions to address non-conformities identified during internal audits.

9. Management Review:

  • Regular Management Reviews: Hold regular management reviews to assess the performance of the ISMS, evaluate the results of internal audits, and identify opportunities for improvement.

10. Continual Improvement:

  • Learn from Incidents: Use lessons learned from security incidents, internal audits, and management reviews to drive continual improvement.
  • Update the ISMS: Periodically review and update the ISMS documentation to ensure its ongoing relevance and effectiveness.

11. Training and Communication:

  • Educate Employees: Conduct training sessions and awareness programs to educate employees about information security policies and practices.
  • Communication: Establish effective communication channels to keep stakeholders informed about the ISMS and its objectives.

Establishing an Information Security Management System (ISMS) involves the implementation of various processes, each contributing to the overall effectiveness of information security within the organization. The processes are often organized within the framework of the Plan-Do-Check-Act (PDCA) cycle. Below are key processes and their interactions needed for the establishment and operation of an ISMS:

1. Plan:

  • Establish the ISMS: Define the scope, policy, and objectives of the ISMS.
  • Conduct Risk Assessment:Identify and assess risks to information assets.
  • Define Controls: Select and implement controls to mitigate identified risks.
  • Develop Documentation: Create documented information such as policies, procedures, and risk assessment reports.
  • Training and Awareness: Provide training to employees to ensure they are aware of information security policies and procedures.

2. Do:

  • Implement Controls: Put in place the selected information security controls.
  • Documentation Management: Establish a system for managing and maintaining documentation related to the ISMS.
  • Training Implementation: Implement training programs to enhance the skills and awareness of employees.
  • Incident Response: Develop and implement an incident response plan to address and mitigate security incidents.
  • Communication: Establish effective communication channels for disseminating information related to the ISMS.

3. Check:

  • Monitor and Measure: Monitor and measure the performance of information security controls.
  • Internal Audits: Conduct internal audits to assess compliance and effectiveness.
  • Review Documentation: Regularly review and update documented information to reflect changes in the organization’s context.
  • Performance Evaluation: Evaluate the performance of the ISMS against established objectives and targets.

4. Act:

  • Management Review: Hold regular management reviews to assess the overall performance of the ISMS.
  • Corrective Actions: Implement corrective actions to address non-conformities and improve the ISMS.
  • Continuous Improvement: Identify opportunities for continual improvement and make necessary adjustments to enhance the ISMS.

Interactions:

  • Risk Management and Controls: The risk assessment process informs the selection and implementation of controls to mitigate identified risks.
  • Documentation and Training: Documented information guides training programs, ensuring that employees are aware of and understand relevant information security policies and procedures.
  • Incident Response and Communication: Effective communication channels are critical during incident response to ensure timely and accurate information dissemination.
  • Internal Audits and Corrective Actions: Findings from internal audits may lead to corrective actions, contributing to the continual improvement of the ISMS.
  • Management Review and Continuous Improvement: The management review process identifies areas for improvement, driving ongoing enhancements to the ISMS.
  • Monitoring and Performance Evaluation: Ongoing monitoring and performance evaluation provide data for management reviews and continuous improvement initiatives.

By integrating these processes within the PDCA cycle and ensuring their effective interactions, organizations can establish a robust and continually improving ISMS that meets the requirements of ISO/IEC 27001. The key is to maintain a cycle of planning, implementing, monitoring, and improving to adapt to changes in the organization’s context and evolving information security risks. secret to the success of maintaining your information security management system to meet clause 4.4 is having the commitment to information security from senior management, whilst also having the technology to make its administration and management a lot easier for everyone involved; information security officers, senior management, staff, suppliers and the auditors themselves. External auditors will want to see the spirit of ISO 27001 being demonstrated and that starts with the senior management and their commitment to the technology being used to coordinate, control and demonstrate everything else works as expected.

Implement Information security management system

Clause 4.4, focuses on the “Information Security Management System (ISMS) and its scope.” This clause outlines the requirements related to establishing and maintaining the scope of the ISMS. The specific documents and records required for this clause include:

Documents:

  1. ISMS Scope Statement: Document that defines the boundaries, applicability, and limitations of the ISMS.
  2. Scope Exclusions (if any): If certain aspects are excluded from the scope, document the reasons and justifications for these exclusions.
  3. External and Internal Issues Documentation: Records that detail the organization’s analysis of external and internal issues relevant to the ISMS.
  4. Interested Parties and Their Requirements: Documentation listing interested parties relevant to the ISMS and their associated requirements.

Records:

  1. Scope Documentation Review Records: Records of reviews conducted to ensure the continued suitability, adequacy, and effectiveness of the ISMS scope.
  2. Scope Changes Records: Records of any changes made to the ISMS scope and the reasons for those changes.
  3. Communication Records: Records of communications related to the establishment, review, and changes to the ISMS scope.
  4. Documented Information Control Records: Records demonstrating the control of documented information, ensuring its availability and protection.
  5. Record of Scope Exclusions Authorization: If exclusions are made from the ISMS scope, document the authorization process, including the reasons and approvals.
  6. Records of Analysis of External and Internal Issues: Records detailing the analysis of external and internal issues, including how they might affect the ISMS.
  7. Interested Parties and Requirements Analysis Records: Records outlining the analysis of interested parties and their relevant requirements.
  8. Management Review Records: Records of management reviews related to the ISMS scope, including decisions and actions.
  9. Results of Risk Assessment: Records of risk assessments conducted to identify potential threats and vulnerabilities relevant to the ISMS scope.
  10. Results of Legal and Regulatory Compliance Assessments: Records of assessments verifying compliance with legal and regulatory requirements relevant to the ISMS scope.

ISO 27001:2022 Clause 4.3 Determining the scope of the information security management system


The organization shall determine the boundaries and applicability of the information security
management system to establish its scope.
When determining this scope, the organization shall consider:
a] the external and internal issues referred to in 4.1;
h] the requirements referred to in 4.2;
c) interfaces and dependencies between activities performed by the organization, and those that are performed by other organizations.
The scope shall be available as documented information.

The organization shall determine the boundaries and applicability of the information security
management system to establish its scope.

Determining the boundaries and applicability of the Information Security Management System (ISMS) is a crucial step in establishing its scope. The scope defines the extent and limits of the ISMS and outlines what information, assets, and processes are covered by the system. Here are key steps to determine the boundaries and applicability of the ISMS:

  1. Define Organizational Boundaries: Clearly identify and define the organizational units, departments, and locations that will be included in the scope of the ISMS. Consider the entire organization, including remote offices, subsidiaries, and third-party relationships.
  2. Identify Assets: Identify and catalog the information assets within the organizational boundaries. This includes data, systems, networks, applications, and any other assets that are critical to the organization’s information security.
  3. Consider Outsourced Processes: If the organization relies on third-party services or outsourced processes that involve information processing, include these in the scope. This could encompass cloud services, IT outsourcing, or other external providers.
  4. Define Information Security Objectives: Establish clear information security objectives and goals for the organization. These objectives will help determine what aspects of the organization’s operations need to be included in the scope of the ISMS.
  5. Consider Legal and Regulatory Requirements: Identify and understand the legal and regulatory requirements applicable to the organization. The scope of the ISMS should encompass areas that are subject to these requirements, ensuring compliance.
  6. Involve Relevant Stakeholders: Engage with key stakeholders, including management, employees, and external partners, to gather input on what areas should be covered by the ISMS. Consider their perspectives and concerns when defining the scope.
  7. Review Business Processes: Examine the organization’s business processes and workflows to determine where information is created, processed, transmitted, and stored. Include these processes in the scope of the ISMS.
  8. Assess Risk: Conduct a risk assessment to identify and analyze potential risks to the organization’s information assets. This assessment will help determine which areas are critical and should be within the scope of the ISMS.
  9. Consider Future Growth and Changes: Anticipate future changes, expansions, or contractions in the organization. Ensure that the scope of the ISMS is flexible enough to accommodate these changes and can adapt to evolving business needs.
  10. Document the Scope: Clearly document the scope of the ISMS, detailing the organizational boundaries, assets included, and the rationale for these decisions. This documentation is essential for communication and for maintaining clarity over time.
  11. Communicate the Scope: Clearly communicate the established scope to all relevant stakeholders, including employees, management, and external partners. Ensure that everyone is aware of what is covered by the ISMS and what is not.
  12. Regularly Review and Update: Establish a process for regularly reviewing and updating the scope of the ISMS. This ensures that changes in the organization’s environment are reflected in the scope, and the ISMS remains effective.

By following these steps, an organization can establish a well-defined and appropriately scoped ISMS that aligns with its business objectives, legal obligations, and information security goals. The clarity provided by a well-defined scope contributes to the effectiveness of the ISMS in protecting critical information assets.

How to set the scope of the ISMS

Setting the scope of the Information Security Management System (ISMS) is a critical step in ensuring that the organization’s information security efforts are focused and effective. The in-scope activity will be much more logical to consider once you have completed the work for 4.1 and 4.2. You’ll probably consider the organisation, subsidiaries, divisions, departments, products, services, physical locations, mobile workers, geographies, systems and processes for your scope as the information assurance and risk assessment work will be following those parts of your organisation that need to be protected. Remember to also think about what the powerful stakeholder interested parties will expect too. If you did look at leaving any part of the organisation out of scope, what would the impact be for those powerful interested parties? Would you also have to run multiple systems and end up confusing staff about what was in and out of scope in the way they worked? What parts of the business need to create, access or process the information assets you see as valuable? These would almost certainly need to be in scope if the pressures were driven externally by customers for satisfying their information assurance needs. For example, you might focus on your product development and delivery but would still have to look at the people, processes etc around it too. Also think about what you can and can’t control or influence. It could be minutes of effort to get this work done or might take considerably longer in a larger enterprise where it can be politically and practically challenging to determine a controllable scope. ISO certification bodies like UKAS are pushing more towards ‘whole organisation’ scope too and powerful customers will generally expect that as well. Here’s a step-by-step guide on how to set the scope of the ISMS:

  1. Define Organizational Boundaries: Clearly identify the organizational units, departments, and locations that will be included in the ISMS. This could include all business units, subsidiaries, remote offices, and any other entities that handle or have access to sensitive information.
  2. Identify Information Assets: Catalog and identify the information assets within the defined organizational boundaries. This includes data, systems, networks, applications, and any other assets that are critical to the organization’s operations.
  3. Consider External Relationships: Take into account external relationships and third-party connections that involve the processing or sharing of information. Include these relationships in the scope if they have a direct impact on the organization’s information security.
  4. Understand Legal and Regulatory Requirements: Identify and understand the legal and regulatory requirements applicable to the organization. Ensure that the scope of the ISMS encompasses areas subject to these requirements to achieve compliance.
  5. Define Information Security Objectives: Establish clear information security objectives for the organization. These objectives should align with the organization’s overall goals and help guide the determination of the scope.
  6. Conduct a Risk Assessment: Perform a thorough risk assessment to identify and analyze potential risks to the organization’s information assets. Assess the criticality of different assets and processes to help prioritize them in the ISMS scope.
  7. Involve Key Stakeholders: Engage with relevant stakeholders, including senior management, department heads, IT staff, legal, and compliance teams. Gather input on what aspects of the organization’s operations should be included in the ISMS scope.
  8. Review Business Processes: Examine the organization’s business processes to understand how information is created, processed, transmitted, and stored. Include these processes in the scope to ensure comprehensive coverage.
  9. Consider Scope Limitations: Clearly define any limitations or exclusions to the scope of the ISMS. This might include specifying certain business units or processes that are intentionally excluded due to unique circumstances or specific business reasons.
  10. Document the Scope Statement: Develop a comprehensive scope statement that clearly outlines the organizational boundaries, information assets included, and any limitations. The scope statement should be documented and easily accessible for reference.
  11. Communicate the Scope: Clearly communicate the established scope to all relevant stakeholders. This includes employees, management, external partners, and any other parties affected by the ISMS. Ensure everyone understands what is covered and what is not.
  12. Regularly Review and Update: Establish a process for regularly reviewing and updating the ISMS scope. Changes in the organization’s structure, business processes, or external relationships may necessitate adjustments to the scope to maintain relevance.
  13. Align with Business Objectives: Ensure that the scope aligns with the overall business objectives of the organization. The ISMS should support the organization’s mission and goals while effectively managing information security risks.
  14. Seek Management Approval: Obtain formal approval from senior management for the defined scope. This ensures that the leadership is aware of and supports the boundaries and objectives of the ISMS.

By following these steps, an organization can establish a well-defined and appropriate scope for its ISMS. A clearly defined scope is essential for focusing efforts, allocating resources effectively, and ensuring that the ISMS addresses the most critical aspects of information security within the organization. Let’s walk through an example of setting up the scope for an Information Security Management System (ISMS). In this scenario, let’s consider a fictional company, XYZ Corporation, that provides online retail services. The goal is to establish a well-defined scope for their ISMS:

  1. Define Organizational Boundaries: XYZ Corporation operates globally and has multiple departments, including IT, sales, customer service, and logistics. The ISMS will cover all departments and locations where sensitive information is processed.
  2. Identify Information Assets:
    • Customer databases
    • Financial systems
    • E-commerce platforms
    • Employee records
    • Intellectual property databases
  3. Consider External Relationships: XYZ Corporation relies on a third-party cloud service for hosting its e-commerce platform. The ISMS will cover the interactions and information flows with this external service provider
  4. Understand Legal and Regulatory Requirements: XYZ Corporation is subject to data protection laws in the countries where it operates. The ISMS will cover compliance with these laws, including GDPR for European customers and local data protection regulations.
  5. Define Information Security Objectives:
    • Protect customer data from unauthorized access.
    • Ensure the availability and integrity of the e-commerce platform.
    • Comply with relevant data protection regulations.
    • Safeguard intellectual property and trade secrets.
  6. Conduct a Risk Assessment: Identify and assess risks associated with data breaches, system downtime, and regulatory non-compliance. Prioritize risks to determine the focus areas of the ISMS.
  7. Involve Key Stakeholders: Engage with IT, legal, compliance, and department heads to gather input on critical areas for information security. Consider feedback from senior management and employees.
  8. Review Business Processes: Examine how information is handled throughout the organization, from customer order processing to shipping. Include all processes that involve the creation, processing, and storage of sensitive information.
  9. Document Limitations: Specify that personal devices used by employees for work purposes are out of scope for the ISMS. This limitation is due to challenges in controlling the security of personal devices.
  10. Include Legal or Regulatory References:Reference relevant data protection laws in the scope documentation to emphasize the commitment to compliance.
  11. Communicate with Stakeholders:Clearly communicate the ISMS scope to all employees, especially those involved in handling sensitive information. Ensure that external partners are aware of the scope’s limitations.
  12. Document in the Scope Statement:Include a dedicated section in the ISMS documentation that clearly outlines the scope. Document what is included, what is excluded, and the rationale behind these decisions.
  13. Update and Review:Establish a regular review process to ensure that the ISMS scope remains aligned with the organization’s evolving business environment and any changes in legal or regulatory requirements.
  14. Obtain Management Approval: Seek formal approval from senior management for the established ISMS scope. This ensures that leadership endorses the boundaries and objectives of the ISMS.
  15. Educate ISMS Users: Provide training to employees regarding the ISMS scope, especially those who handle sensitive information. Ensure that they understand their roles in maintaining the security of the included areas.

ISMS Scope Statement for XXX Solutions:

1. Organizational Boundaries: The ISMS covers all departments and business units within XXX Solutions, including software development, IT infrastructure, human resources, and administration.

2. Information Assets Included:

  • The following information assets are included in the scope:
    • Client data, including project details and sensitive information shared by clients.
    • Employee records, including personal information and HR-related data.
    • Intellectual property, source code, and proprietary software developed by XXX Solutions.
    • Financial data related to invoicing and transactions.

3. External Relationships: The ISMS includes interactions with external service providers and cloud platforms that are involved in software development, hosting, and other relevant processes.

4. Legal and Regulatory Requirements: The scope encompasses compliance with data protection laws, intellectual property regulations, and any other legal requirements applicable to the software development industry in the regions where XXX Solutions operates.

5. Information Security Objectives:

  • The ISMS aims to achieve the following key objectives:
    • Protect client confidentiality and ensure the secure handling of client data.
    • Safeguard intellectual property and prevent unauthorized access to source code.
    • Ensure the availability and integrity of IT systems to prevent service disruptions.
    • Comply with data protection laws and regulations.

6. Risk Assessment: The ISMS focuses on addressing risks associated with data breaches, unauthorized access, system vulnerabilities, and compliance failures. Risks are assessed regularly to inform security measures.

7. Stakeholder Involvement: Key stakeholders, including senior management, IT professionals, legal and compliance teams, and client representatives, are consulted to ensure that their concerns and requirements are considered in defining the scope.

8. Business Processes: All business processes involving the creation, processing, and storage of sensitive information are included. This covers software development, project management, client communications, and administrative processes.

9. Documented Limitations: Personal devices used by employees for work purposes are considered out of scope due to challenges in controlling the security of personal devices. This limitation is documented to provide transparency.

10. Legal and Regulatory References: References to data protection laws and industry-specific regulations are included in the scope documentation to emphasize the commitment to compliance.

11. Communication with Stakeholders: The defined scope is communicated to all employees through training sessions and documentation. Clients are informed about the security measures in place to protect their information.

12. Scope Documentation: The ISMS documentation includes a dedicated section detailing the scope, explicitly listing what is covered and providing a rationale for any exclusions.

13. Regular Review and Update: A periodic review process is established to ensure the ongoing relevance of the scope. Changes in business operations, legal requirements, or technology are considered during these reviews.

14. Management Approval: Formal approval is sought from senior management to endorse and support the defined ISMS scope.

15. Employee Education: Employees are educated about their roles and responsibilities within the ISMS scope. Training programs emphasize the importance of information security in their daily activities.

This example demonstrates a systematic approach to setting up the scope for an ISMS. By following these steps, XYZ Corporation can establish a clear and well-defined scope that aligns with its business objectives and effectively manages information security risks.

How to document ‘out-of-scope’

Documenting the ‘out-of-scope’ elements is a crucial aspect of clearly defining the boundaries of your Information Security Management System (ISMS). This documentation helps communicate what is intentionally excluded from the scope and ensures transparency about the areas or processes that are not covered by the ISMS. Establish clear criteria for determining what falls outside the scope of the ISMS. This could include specific business units, processes, information assets, or locations. Create a list of the specific items or areas that are considered ‘out-of-scope.’ Be explicit about what is excluded and provide a brief explanation for each item. Clearly articulate the rationale for excluding each item from the ISMS scope. This could be due to low risk, business-specific reasons, or the nature of certain processes that are managed separately. Specify any limitations associated with the out-of-scope items. This could include constraints on resources, technology, or other factors that influence the decision to exclude certain elements.If applicable, reference any legal or regulatory requirements that explicitly exclude certain elements from the scope. Ensure that the organization remains compliant with relevant laws and regulations. Clearly communicate the decision to exclude specific elements from the ISMS to relevant stakeholders, including management, employees, and external partners. Transparency is crucial for understanding and acceptance. Include the details of ‘out-of-scope’ items in the official scope statement of the ISMS documentation. This could be a separate section clearly indicating what is not covered. Regularly review and update the documentation on ‘out-of-scope’ items. Changes in business processes, organizational structure, or regulatory landscape may require adjustments to the scope. Ensure that the decision to exclude certain elements aligns with the results of risk assessments. If an item is excluded due to low risk, ensure that the risk assessment supports this decision. Anticipate potential changes in the organization’s environment that may impact the ‘out-of-scope’ items. Ensure that the scope remains relevant and can adapt to evolving business needs. Seek formal approval from senior management for the documented ‘out-of-scope’ items. This helps ensure that key decision-makers are aware of and endorse the limitations. Provide training and education to individuals involved in the implementation and operation of the ISMS. Ensure they understand the implications of ‘out-of-scope’ elements on their responsibilities. You should also carefully note the ‘out of scope’ areas for the ISMS too, wrapped up alongside the key interfaces and dependencies between activities performed by the organisation and those that are performed by other organisations. At a simplistic level, let’s imagine you are a software developer and rely on outsourcing of the datacentre for hosting of the service to customers. You’d probably clarify that the scope for your 4.3 is that within your organisation for the people and the software itself, but would put the boundaries and activities of the data centre out of your controlled scope – after all you would expect them to also maintain their own trusted ISMS. It is the same for physical property – if there is a reliance on a landlord for certain work (e.g. loading, barriers and reception control) that might form a boundary where the physical location security itself is out of scope for your control and you’d work your ISMS activity within that property.

When determining this scope, the organization shall consider the external and internal issues related to Information security management system

when determining the scope of an Information Security Management System (ISMS), it’s essential for the organization to consider both external and internal issues. This process is part of the broader context analysis that helps shape the boundaries of the ISMS and ensures that it aligns with the organization’s goals and context. Here’s a breakdown of how external and internal issues are considered:

External Issues:

  1. Legal and Regulatory Environment: Identify and understand the legal and regulatory requirements relevant to information security. This includes data protection laws, industry-specific regulations, and any other legal obligations related to the handling of sensitive information.
  2. Industry Standards and Best Practices: Consider industry-specific standards and best practices related to information security. This could include ISO/IEC 27001, NIST Cybersecurity Framework, or other relevant standards that provide guidance on effective security measures.
  3. Market and Customer Expectations: Analyze market trends and customer expectations regarding information security. Consider the specific security requirements outlined by clients, partners, and stakeholders to meet market demands and enhance trust.
  4. Technological Landscape: Stay informed about advancements and changes in technology that may impact information security. This includes emerging threats, new vulnerabilities, and technologies that could enhance or pose risks to the organization’s security posture.
  5. Competitive Landscape: Understand how competitors approach information security. This analysis can provide insights into industry benchmarks and help the organization set its information security practices in line with or ahead of industry standards.
  6. Global and Geopolitical Factors: Consider global and geopolitical factors that may influence information security. This could include geopolitical tensions, international cyber threats, and other factors that may have implications for the organization’s security.

Internal Issues:

  1. Organizational Objectives and Strategy: Align the scope of the ISMS with the overall objectives and strategic goals of the organization. Ensure that information security measures support and contribute to the achievement of broader organizational aims.
  2. Business Processes: Understand how information is used, processed, and shared across different business processes within the organization. Identify critical processes and ensure they are included in the scope of the ISMS.
  3. Information Assets: Catalog and assess the organization’s information assets. This includes data, systems, applications, intellectual property, and any other assets that are crucial to the organization’s operations.
  4. Organizational Structure: Consider the organizational structure, including departments, business units, and geographical locations. Determine which parts of the organization will fall within the scope of the ISMS.
  5. Risk Appetite and Tolerance: Define the organization’s risk appetite and tolerance for information security. This helps in prioritizing security measures and determining the level of risk the organization is willing to accept.
  6. Existing Controls and Security Measures: Evaluate the effectiveness of existing controls and security measures. Identify areas where improvements or additional measures are needed to strengthen the organization’s security posture.
  7. Employee Awareness and Competence: Assess the level of awareness and competence of employees regarding information security. This may influence the scope by highlighting areas that require additional training or awareness programs.
  8. Third-Party Relationships: Consider the organization’s relationships with third parties, such as suppliers and partners. Assess the impact of these relationships on information security and include relevant aspects in the ISMS scope.

Integration of External and Internal Issues:

  • Stakeholder Input: Gather input from key stakeholders, including management, employees, and external partners. Stakeholder perspectives help ensure that the ISMS scope is comprehensive and addresses the concerns of all relevant parties.
  • Context Analysis: Conduct a thorough analysis of the external and internal issues to create a context for information security. This analysis provides the foundation for determining the scope and setting objectives within the ISMS.
  • Documentation: Document the findings from the analysis of external and internal issues. This documentation will serve as a reference point for decision-making, scope definition, and ongoing management of the ISMS.

By considering both external and internal issues, organizations can establish an ISMS scope that is well-aligned with their context, strategic goals, and the expectations of stakeholders. This holistic approach helps organizations build a robust and contextually relevant information security framework.

When determining this scope, the organization shall consider the requirements of interested parties relevant to Information security management system.

Considering the requirements of interested parties is a crucial aspect when determining the scope of an Information Security Management System (ISMS). Interested parties are individuals or organizations that can affect, be affected by, or perceive themselves to be affected by a decision or activity related to the ISMS. These parties may have specific requirements and expectations concerning information security. Here’s a breakdown of how to consider the requirements of interested parties in determining the ISMS scope:

Identify Interested Parties:

  1. Internal Parties:
    • Employees: Consider the expectations and requirements of employees regarding the protection of their personal information and the security of the systems they use.
    • Management: Understand the strategic objectives and expectations of the management regarding information security.
    • IT Department: Identify the technical requirements and expectations of the IT department in terms of network security, system integrity, and data protection.
  2. External Parties:
    • Customers: Identify the expectations of customers regarding the confidentiality, integrity, and availability of their data.
    • Regulatory Authorities: Consider the legal and regulatory requirements imposed by governmental or industry regulatory bodies.
    • Business Partners: Understand the contractual obligations and security expectations of business partners, suppliers, and other external stakeholders.
    • Industry Associations: If applicable, consider any standards or guidelines set by industry associations relevant to information security.

Assess Requirements of Interested Parties:

  1. Legal and Regulatory Requirements: Identify and understand the legal and regulatory requirements imposed by relevant authorities. This may include data protection laws, industry-specific regulations, and other compliance obligations.
  2. Contractual Obligations: Review contracts, agreements, and service level agreements (SLAs) with customers and business partners. Identify any specific information security requirements outlined in these agreements.
  3. Customer Expectations: Engage with customers through surveys, feedback sessions, or direct communication to understand their expectations regarding the security of their data and services.
  4. Internal Stakeholder Expectations: Interview or survey internal stakeholders, including employees and management, to gather their expectations and requirements for information security within the organization.
  5. Regulatory Bodies: Stay informed about any changes in laws and regulations related to information security. Regularly monitor updates from regulatory bodies that may impact the organization.

Integration into ISMS Scope:

  1. Prioritize Requirements: Prioritize the identified requirements based on their significance and impact on the organization. Focus on requirements that align with the organization’s strategic objectives and overall risk management approach.
  2. Risk Assessment: Incorporate the requirements into the risk assessment process. Assess the risks associated with non-compliance with the identified requirements to prioritize actions and controls within the ISMS.
  3. Document Requirements: Clearly document the requirements of interested parties in the documentation of the ISMS. This documentation serves as a reference point for decision-making and continuous improvement.
  4. Communication: Communicate the ISMS scope and the organization’s commitment to meeting the requirements of interested parties to internal and external stakeholders. Transparency builds trust and confidence.
  5. Stakeholder Engagement: Engage with interested parties throughout the process. Regularly review and update the ISMS scope to ensure that it continues to meet the expectations of stakeholders.

By systematically identifying, assessing, and integrating the requirements of interested parties into the ISMS scope, organizations can establish a comprehensive and effective information security framework. This approach helps in building trust, ensuring compliance, and aligning the ISMS with the expectations of relevant stakeholders.

When determining this scope, the organization shall consider the interfaces and dependencies between activities performed by the organization, and those that are performed by other organizations

Considering interfaces and dependencies with other organizations is a critical aspect when determining the scope of an Information Security Management System (ISMS). This involves understanding how activities performed by the organization interact with those carried out by external entities, such as suppliers, partners, or service providers. Addressing these interfaces and dependencies ensures a comprehensive and effective approach to information security. Here are steps to consider:

Identify External Interfaces and Dependencies:

  1. Suppliers and Service Providers: Identify external entities, including suppliers and service providers, that interact with your organization’s information assets or processes. This may involve IT service providers, cloud services, and other third-party vendors.
  2. Business Partners and Customers: Consider how your organization interacts with business partners and customers. This could include data exchanges, collaborative projects, or any shared information systems.
  3. Governmental or Regulatory Bodies: Recognize any interactions and dependencies related to regulatory compliance. Understand reporting requirements, audit processes, and any external assessments that may impact information security.
  4. Industry Standards and Frameworks: Consider interfaces related to industry standards, frameworks, or certifications. This could involve alignment with ISO/IEC 27001, NIST Cybersecurity Framework, or other relevant standards.

Assess Information Security Implications:

  1. Data Flows: Map the flow of information between your organization and external entities. Understand the types of data exchanged, the frequency of exchanges, and the criticality of the information.
  2. Security Controls: Evaluate the security controls implemented by external entities. Ensure that these controls align with the security objectives of your organization and provide adequate protection for shared information.
  3. Contractual Agreements: Review contractual agreements with external entities to identify information security obligations and responsibilities. Ensure that expectations for security measures are clearly defined.
  4. Risk Assessment: Assess the risks associated with external interfaces and dependencies. Consider potential threats, vulnerabilities, and the impact on information security if these interfaces are not properly managed.

Integration into ISMS Scope:

  1. Include External Interfaces in Scope: Clearly define the external interfaces and dependencies that are considered in scope for the ISMS. This includes activities, systems, and information flows that involve external parties.
  2. Security Objectives for Interfaces: Establish security objectives specifically addressing the interfaces and dependencies with external organizations. Ensure that these objectives align with the overall goals of the ISMS.
  3. Collaborate on Security Measures: Collaborate with external entities to establish mutually agreed-upon security measures. This could involve joint risk assessments, sharing of best practices, and implementing controls that benefit both parties.
  4. Communication and Awareness: Communicate the ISMS scope and security measures to relevant external entities. Ensure that both organizations are aware of their roles and responsibilities in maintaining information security.
  5. Monitoring and Review: Implement monitoring mechanisms to continuously assess the effectiveness of security controls related to external interfaces. Regularly review the security posture of external entities to ensure ongoing compliance.
  6. Incident Response Planning: Develop incident response plans that account for potential security incidents involving external interfaces. Collaborate with external entities to establish clear communication and response procedures.

By considering interfaces and dependencies with other organizations, the ISMS can address potential risks and enhance the overall security posture. This collaborative approach helps ensure a more robust and resilient information security framework that extends beyond the boundaries of the organization.

The scope shall be available as documented information.

This documentation serves as a reference and communication tool, ensuring that stakeholders within and outside the organization are aware of the boundaries, objectives, and limitations of the ISMS. Here are key points regarding documenting the ISMS scope:

  1. Scope Statement: Develop a comprehensive scope statement that clearly outlines the organizational boundaries, information assets included, and any limitations or exclusions. The scope statement should provide a clear and concise overview of what the ISMS covers.
  2. Inclusion of Relevant Information: Ensure that the documented scope includes all relevant information necessary to understand the scope. This may encompass internal and external factors, interested parties, and any specific considerations that influenced the determination of the scope.
  3. Rationale for Exclusions: If any areas or activities are intentionally excluded from the scope, clearly document the rationale behind these exclusions. This transparency helps stakeholders understand the reasons for certain decisions.
  4. Legal and Regulatory References: Include references to legal and regulatory requirements relevant to the scope. This emphasizes the organization’s commitment to compliance and ensures that the ISMS aligns with applicable laws and regulations.
  5. Interfaces and Dependencies: Document information about external interfaces and dependencies, emphasizing how interactions with other organizations or entities are managed to maintain information security.
  6. Review Dates: Include the date of the last review of the ISMS scope. Regular reviews ensure that the scope remains aligned with the organization’s context, objectives, and any changes in the internal or external environment.
  7. Communication of Changes: Clearly communicate any changes to the ISMS scope to relevant stakeholders. This ensures that everyone is aware of modifications and can adjust their practices accordingly.
  8. Accessible and Distributed: Make the documented scope accessible to all relevant stakeholders. This may involve distributing the information through internal communication channels or making it available on a centralized platform.
  9. Controlled Document: Implement document control measures to ensure the accuracy and integrity of the ISMS scope documentation. This may include version control, access restrictions, and regular audits.
  10. Training and Awareness: Incorporate the ISMS scope into training and awareness programs for employees and other stakeholders. This helps in ensuring that everyone understands the scope and their role in supporting information security.
  11. Alignment with Policies and Procedures: Ensure that the documented ISMS scope aligns with the organization’s information security policies and procedures. Consistency across these documents enhances the effectiveness of the overall information security framework.
  12. Integration with Risk Management: Connect the ISMS scope documentation with the organization’s risk management processes. This integration helps in addressing risks associated with the defined scope.

By documenting the ISMS scope, organizations create a foundation for effective communication, transparency, and accountability in managing information security. This documentation not only facilitates compliance with ISO/IEC 27001 but also supports ongoing improvement and adaptation to changing circumstances.

Let’s create a hypothetical example of establishing the scope of an Information Security Management System (ISMS) for a technology company, TechGuard Solutions. In this example, we’ll consider external and internal issues, requirements of interested parties, and interfaces/dependencies.

1. External and Internal Issues:

External Issues:

  • Legal and Regulatory Environment:
    • Compliance with data protection laws, industry standards, and international regulations.
  • Market Trends and Customer Expectations:
    • Continuous monitoring of emerging threats and customer expectations for robust information security practices.
  • Technological Landscape:
    • Adaptation to evolving technologies, ensuring security measures keep pace.
  • Competitive Landscape:
    • Regular assessment of industry competitors and benchmarks for information security.

Internal Issues:

  • Organizational Objectives and Strategy:
    • Integration of information security with overall business objectives and strategic goals.
  • Business Processes:
    • Mapping and understanding critical business processes that involve sensitive information.
  • Information Assets:
    • Cataloging and assessing the organization’s information assets, including intellectual property, customer data, and proprietary technologies.
  • Risk Appetite and Tolerance:
    • Aligning information security measures with the organization’s risk appetite and tolerance.

2. Requirements of Interested Parties:

Identified Interested Parties and Their Requirements:

  • Customers:
    • Requirements for the protection of customer data and assurance of service availability.
  • Regulatory Authorities:
    • Compliance with data protection laws, reporting, and auditing requirements.
  • Business Partners:
    • Contractual obligations related to information security, data handling, and confidentiality.
  • Employees:
    • Expectations for the secure handling of personal information and adherence to internal security policies.

3. Interfaces and Dependencies:

Identified Interfaces and Dependencies:

  • Suppliers and Service Providers:
    • Dependence on third-party cloud services and software providers for various business functions.
  • Business Partners and Customers:
    • Collaborative projects and shared information systems with business partners and customers.
  • Regulatory Bodies:
    • Interfaces related to compliance reporting, audits, and assessments by regulatory bodies.
  • Industry Standards and Frameworks:
    • Interfaces related to the adoption of industry standards for information security.

4. Integration into ISMS Scope:

  • Scope Statement:
    • The ISMS at TechGuard Solutions encompasses all departments and business units involved in the development, delivery, and support of technology solutions. It includes the protection of customer data, intellectual property, and compliance with legal and regulatory requirements.
  • Rationale for Exclusions:
    • Personal devices used by employees for work purposes are excluded from the scope due to challenges in controlling the security of such devices.
  • Legal and Regulatory References:
    • The scope is aligned with GDPR and other relevant data protection laws, as well as industry standards for information security.
  • Interfaces and Dependencies:
    • The ISMS scope acknowledges dependencies on third-party cloud services, collaborative projects with business partners, and compliance interfaces with regulatory bodies.
  • Review and Update:
    • The ISMS scope is subject to regular reviews to ensure alignment with changing external and internal factors, stakeholder requirements, and emerging technologies.
  • Communication:
    • The ISMS scope is communicated internally to employees and externally to business partners and customers. Any changes to the scope are transparently communicated.

This example illustrates how an organization like TechGuard Solutions might establish the scope of its ISMS by systematically considering external and internal issues, the requirements of interested parties, and interfaces/dependencies. This comprehensive approach helps ensure that the ISMS is well-aligned with the organization’s context and effectively addresses information security risks.

ISO 27001:2022 Clause 4.2 Understanding the needs and expectations of interested parties

ISO 27001:2022 Requirements

The organization shall determine:

  1. interested parties that are relevant to the information security management system;
  2. the relevant requirements of these interested parties;
  3. which of these requirements will be addressed through the information security management system.

Note: The requirements of interested parties can include legal and regulatory requirements and contractual obligations.

The organization shall determine interested parties that are relevant to the information security management system.

Identifying and understanding the interested parties relevant to the Information Security Management System (ISMS) is a crucial step in establishing an effective and comprehensive security framework. Interested parties are individuals or groups that can affect, be affected by, or perceive themselves to be affected by the organization’s decisions or activities related to information security. ISO/IEC 27001, the international standard for information security management, emphasizes the importance of considering interested parties in the context of an ISMS. The standard requires organizations to establish a process for identifying these interested parties and determining their relevant requirements. Here’s a brief overview of the steps involved:

  1. Identify Interested Parties: Make a list of individuals, groups, or entities that have an interest in the information security of the organization. This can include employees, customers, suppliers, regulators, shareholders, and other stakeholders.
  2. Determine Relevant Requirements: Understand the expectations and requirements of each identified interested party concerning information security. This involves analyzing their needs, concerns, and any legal or regulatory obligations that may apply.
  3. Assess the Impact: Evaluate the potential impact of the interested parties on the organization’s information security objectives. Consider how their expectations and requirements may influence the ISMS.
  4. Prioritize and Document: Prioritize the interested parties based on the significance of their impact. Document the identified interested parties and their relevant requirements in the context of the ISMS.
  5. Incorporate into the ISMS: Integrate the identified interested parties and their requirements into the development, implementation, and maintenance of the ISMS. This ensures that the security controls and processes address the needs and expectations of these stakeholders.
  6. Monitor and Review: Regularly review and update the list of interested parties and their requirements. As the organizational context changes, new stakeholders may emerge, and their expectations may evolve.

By actively considering and addressing the concerns of interested parties, organizations can enhance the effectiveness and acceptance of their ISMS. This approach aligns with the broader principles of stakeholder engagement and demonstrates a commitment to managing information security in a holistic and inclusive manner.

 An interested party is a stakeholder – someone, a group or an entity with an interest in your ISMS (or perhaps the organisation itself). You should be able to easily identify many of your interested parties after having completed the internal and external issues that impact the intended outcomes of the information security management system. These will include staff, suppliers, customers, shareholders, directors, prospects, board members, competitors, legislators and regulators, unions etc. Interested parties are not always the obvious ones too – for example hackers and related malicious parties might need consideration, as do the media and others depending on the nature of your business and the issues facing it. However rather than creating a range of one size fits all policies and controls for all your interested parties, it is better to look at those interested parties in terms of their power, interest and support – in simple terms this is about their ability to affect your approach to the ISMS. Then you can develop suitable approaches to demonstrate you have their needs covered . As an example if you had a customer that demands you invest in ISO 27001 and build an independently certified ISO 27001 ISMS would you do that if they were a very small non-influential player? You’d probably think again if that customer was one of many you wanted to win, or a large powerful player in its own right. If a stakeholder is high power and low interest, you should be thinking of that individual or group as a ‘keep satisfied’ stakeholder. Ask yourself, what will you do in your ISMS with policies and controls to keep them satisfied? In this high power and low interest area, you might see organisations like legislators and regulators, very powerful customer groups, shareholders etc. There may also be external auditors and other industry bodies who can affect your business success. Their interest is quite low on a day to day basis, but their power to affect your business goals is high so they need to be kept satisfied – usually from a distance and having an independently certified ISO 27001 certificate goes some way to addressing their needs. The very powerful interested parties for information assurance such as regulators may also prescribe specific ways of working. If an interested party has both high interest and high power, we would call them a key player. These stakeholders should be actively involved. Your senior management team, key department heads, boutique critical suppliers etc. will likely fall into this category. You might actually have some of your intimately engaged important customers in this category. They may be very interested in how you are working day to day as it also impacts them too. It is easy to create long lists of stakeholders to consider but be wary of spending too long on the ones with lower power. Those with lower power and higher interest are in need of keeping informed but may not need to be consulted on what your ISMS covers – you may just need to tell them otherwise they could be a big suck on your time and investment budget! Also, be careful about simply dumping stakeholders you don’t like in the lower power buckets – we saw this happen in one firm. They paid for it later because the stakeholder was actually quite powerful and delayed them achieving their goals because their requirements were not prioritized. Combining this interested parties and stakeholder work with the internal and external issues you have identified in 4.1 helps lead towards a better understanding of where threats and opportunities might stem from in your information security management system.

Steps to identify interested parties relevant to the information security management system

Identifying interested parties relevant to the Information Security Management System (ISMS) involves a systematic process to recognize individuals, groups, or entities that may have an impact on or be impacted by the organization’s information security. Here’s a step-by-step guide to help you identify these stakeholders:

  1. Establish a Team: Form a cross-functional team that includes representatives from various departments within the organization. This team will bring diverse perspectives to the identification process.
  2. Review Documentation: Examine existing documentation, such as organizational charts, contracts, policies, and procedures, to identify parties that may have a stake in the information security of the organization.
  3. Conduct Stakeholder Workshops: Facilitate workshops or interviews with key stakeholders, both internal and external, to gather insights into their expectations, concerns, and requirements related to information security.
  4. Use Surveys and Questionnaires: Develop surveys or questionnaires to collect input from a broader set of stakeholders. This method can help reach individuals who may not be easily accessible for in-person interviews.
  5. Review Legal and Regulatory Requirements: Identify relevant legal and regulatory requirements pertaining to information security. This can include data protection laws, industry standards, and contractual obligations that may specify security expectations.
  6. Examine Industry Best Practices: Research industry best practices and standards related to information security. This can provide insights into common expectations from stakeholders within your specific sector.
  7. Consider Internal Departments: Look within your organization to identify internal departments and teams that may have a vested interest in information security. This includes IT, legal, compliance, human resources, and executive leadership.
  8. Review Incident History: Analyze past incidents related to information security to identify parties that may have been affected or played a role in addressing the incidents. This can provide valuable insights into areas of concern.
  9. Assess Suppliers and Partners: Consider external entities such as suppliers, partners, and contractors that may have access to your organization’s information. Assess their potential impact on your information security.
  10. Evaluate Customer Feedback: Review customer feedback, complaints, and inquiries to identify any security-related concerns or expectations. Customer perceptions can be crucial in understanding the business impact of information security.
  11. Engage with Industry Forums: Participate in industry forums, conferences, and networking events to understand the broader ecosystem and identify stakeholders with common interests in information security.
  12. Regularly Update the Stakeholder Register: Maintain a stakeholder register that includes information on identified stakeholders, their roles, interests, and requirements. Regularly update this register to reflect changes in the organization’s context.

By employing a comprehensive approach that involves multiple sources of information, you can create a thorough understanding of the interested parties relevant to your ISMS. This understanding will be valuable in shaping your information security policies, procedures, and controls to meet the expectations and requirements of these stakeholders.

Examples of Stakeholder analysis

Stakeholder: Executive Leadership Team

  • Interest:
    • High interest in the overall effectiveness of the ISMS.
    • Concerned about the protection of sensitive business information and the potential impact of security incidents on the organization’s reputation.
  • Influence:
    • High influence in setting organizational priorities and allocating resources for information security.
    • Decision-makers for strategic initiatives related to information security.
  • Expectations:
    • Regular updates on the status of the ISMS.
    • Assurance of compliance with relevant laws and regulations.
    • Demonstrable value of information security investments.

Stakeholder: IT Department

  • Interest:
    • High interest in the technical aspects of information security, including network security, system integrity, and data protection.
    • Concerned about vulnerabilities, threats, and incidents that may affect IT infrastructure.
  • Influence:
    • Directly involved in implementing and maintaining technical controls for information security.
    • Key role in incident response and recovery.
  • Expectations:
    • Collaboration with other departments for a holistic approach to information security.
    • Timely communication of security incidents and vulnerabilities.
    • Participation in the design and review of security controls.

Stakeholder: Employees

  • Interest:
    • Varied interest, ranging from concern about the security of personal information to understanding how security measures impact daily tasks.
    • Employees are often the first line of defense against social engineering and insider threats.
  • Influence:
    • Indirect influence through adherence to security policies and practices.
    • May identify security concerns and report incidents.
  • Expectations:
    • Clear and accessible information security policies.
    • Regular training on security best practices.
    • User-friendly security measures that do not overly disrupt workflow.

Stakeholder: Customers

  • Interest:
    • Concerned about the security of their personal and financial information.
    • Trust in the organization’s ability to protect sensitive data.
  • Influence:
    • Can influence the organization’s reputation and success through their perception of the security measures in place.
  • Expectations:
    • Transparent communication about data protection measures.
    • Assurance of compliance with industry standards.
    • Swift notification in the event of a data breach.

Stakeholder: Regulatory Bodies

  • Interest:
    • High interest in ensuring organizations comply with relevant laws and regulations.
    • Concerned about the protection of sensitive information, especially personal and financial data.
  • Influence:
    • Can enforce legal consequences for non-compliance.
    • May set standards and guidelines for information security.
  • Expectations:
    • Evidence of compliance with specific regulations (e.g., GDPR, HIPAA).
    • Cooperation during regulatory audits and investigations.

Stakeholder: Business Partners and Suppliers

  • Interest:
    • Concerned about the security of shared information and potential risks associated with the organization’s information security practices.
  • Influence:
    • May impose contractual obligations related to information security.
    • Could impact business relationships based on the perceived security posture.
  • Expectations:
    • Evidence of compliance with security standards.
    • Collaboration on security assessments and audits.
    • Communication about security incidents that may impact shared data.

Stakeholder: Internal Audit and Compliance Teams

  • Interest:
    • High interest in ensuring that information security controls meet internal policies and external regulatory requirements.
  • Influence:
    • Conduct audits to assess the effectiveness of information security controls.
    • Provide recommendations for improvement.
  • Expectations:
    • Regular updates on the status of information security compliance.
    • Cooperation during audits and implementation of audit recommendations.

Stakeholder: Legal Team

  • Interest:
    • Concerned about legal implications related to information security incidents and breaches.
  • Influence:
    • Involved in the review and creation of contracts with a focus on information security clauses.
    • May provide legal advice on compliance matters.
  • Expectations:
    • Clear documentation of information security measures for legal purposes.
    • Collaboration during the development of contracts with security implications.

The organization shall determine the relevant requirements of these interested parties.

Determining the relevant requirements of interested parties is a critical step in establishing an effective Information Security Management System (ISMS). Once you’ve identified the interested parties, you need to understand their expectations and requirements related to information security. Here’s a guide on how to determine and document these relevant requirements:

  1. Communicate with Stakeholders: Engage in open communication with the identified interested parties. This can be through surveys, interviews, meetings, or other forms of direct interaction. Seek to understand their concerns, expectations, and specific requirements related to information security.
  2. Review Legal and Regulatory Documentation: Examine relevant laws, regulations, and contractual agreements that apply to your organization. Identify information security requirements outlined in these documents, as non-compliance may have legal consequences.
  3. Refer to Industry Standards and Best Practices: Research industry-specific standards and best practices for information security. These may provide guidance on the expectations of stakeholders within your sector and help you establish a baseline for compliance.
  4. Evaluate Internal Policies and Procedures: Review your organization’s internal policies and procedures related to information security. Ensure that they align with the expectations of the identified stakeholders. Identify any gaps that need to be addressed.
  5. Assess Risk and Impact: Evaluate the potential risks and impacts associated with each interested party’s requirements. This assessment helps prioritize and tailor your information security controls to address the most critical concerns.
  6. Consider Customer Feedback: Analyze customer feedback and inquiries related to information security. Understand their expectations and concerns, as these are key components of meeting customer requirements.
  7. Collaborate with Internal Departments: Work closely with internal departments, such as IT, legal, compliance, and human resources, to understand their specific requirements related to information security. Ensure that these requirements are integrated into the ISMS.
  8. Assess Supplier and Partner Requirements: Evaluate the requirements of suppliers, partners, and other external entities that have access to your organization’s information. Incorporate these requirements into your ISMS to manage third-party risks.
  9. Document Requirements Clearly: Clearly document the identified requirements in a structured manner. This documentation should specify the expectations of each interested party and how the organization intends to address them.
  10. Prioritize Requirements: Prioritize the identified requirements based on their importance and impact on the organization’s information security. This prioritization will guide the allocation of resources and efforts.
  11. Update the ISMS Documentation: Ensure that the requirements of interested parties are reflected in the documentation of your ISMS. This includes policies, procedures, risk assessments, and other relevant documents.
  12. Establish a Review Mechanism: Implement a periodic review mechanism to keep the determination of relevant requirements up-to-date. Regularly revisit and reassess the needs and expectations of interested parties in the evolving business environment.

By systematically determining and documenting the relevant requirements of interested parties, your organization can tailor its information security measures to address specific concerns and expectations. This approach enhances the effectiveness of the ISMS and demonstrates a commitment to meeting the needs of stakeholders.

Some examples of requirements of interested parties relevant to ISMS

  1. Customers:
    • Confidentiality: Customers may expect that their personal and sensitive information is kept confidential and not disclosed to unauthorized parties.
    • Data Integrity: Customers may require assurance that their data is accurate, complete, and not subject to unauthorized alterations.
    • Availability: Customers may expect that the services and products they rely on are available without disruption.
  2. Regulatory Authorities:
    • Compliance: Regulatory bodies often have specific information security regulations that organizations must comply with. These may include data protection laws, industry-specific regulations, and cybersecurity standards.
    • Reporting: Regulatory authorities may require organizations to report security incidents and breaches within a specified timeframe.
  3. Employees:
    • Training: Employees may expect to receive regular training on information security awareness and best practices.
    • Access Control: Employees may have requirements related to access controls to ensure that they only have access to the information necessary for their roles.
    • Privacy: Employees may have privacy expectations related to the handling of their personal information.
  4. Business Partners and Suppliers:
    • Data Handling: Partners and suppliers may have requirements regarding how their data is handled, stored, and transmitted.
    • Compliance Verification: Business partners may request evidence of the organization’s compliance with relevant information security standards.
  5. Management and Leadership:
    • Risk Management: Leadership may expect the organization to implement effective risk management processes to identify, assess, and mitigate information security risks.
    • Performance Metrics: Leadership may require performance metrics and reporting on the effectiveness of the ISMS.
  6. IT Department:
    • Security Controls: The IT department may have specific requirements for implementing and maintaining technical security controls, such as firewalls, intrusion detection systems, and antivirus software.
    • Incident Response: Requirements related to incident response, including reporting procedures and mitigation strategies.
  7. Legal and Compliance Teams:
    • Contractual Obligations: Legal teams may have requirements related to the inclusion of specific clauses in contracts to address information security.
    • Legal Compliance: Ensure compliance with relevant laws and regulations to avoid legal consequences.
  8. Shareholders/Investors:
    • Risk Disclosure: Shareholders may require transparent disclosure of information security risks that could impact the organization’s financial performance.
    • Investment Protection: Assurance that information security measures are in place to protect the value of their investments.

The organization shall determine which of these requirements will be addressed through the information security management system

Once an organization has identified the requirements of various interested parties relevant to its Information Security Management System (ISMS), the next step is to determine how these requirements will be addressed within the ISMS. This involves a careful assessment and decision-making process to prioritize and incorporate the identified requirements into the organization’s information security framework. Here’s a guide on how to determine which requirements will be addressed through the ISMS:

  1. Prioritize Requirements: Evaluate the identified requirements based on their significance, potential impact, and criticality to the organization. Prioritize those requirements that align with the organization’s objectives and pose higher risks if not addressed.
  2. Align with ISMS Objectives: Ensure that the selected requirements align with the objectives and scope of the ISMS. The ISMS should be designed to meet the organization’s overall goals, and the selected requirements should contribute to achieving those objectives.
  3. Legal and Regulatory Compliance: Prioritize requirements that are necessary for legal and regulatory compliance. Ensure that the organization’s ISMS addresses these requirements to avoid legal consequences and regulatory non-compliance.
  4. Risk Assessment: Conduct a risk assessment to identify and prioritize requirements based on potential risks to information security. Addressing high-risk requirements is crucial to mitigating significant security threats.
  5. Resource Availability: Consider the resources available to the organization, including budget, personnel, and technology. Select requirements that can be feasibly addressed within the available resources.
  6. Stakeholder Impact: Assess the impact on key stakeholders and prioritize requirements that have a direct impact on customer satisfaction, employee well-being, and other critical stakeholders.
  7. Integration with Existing Processes: Ensure that the selected requirements can be seamlessly integrated into existing processes and procedures. Integration facilitates a smoother implementation of information security controls.
  8. Continuous Improvement: Consider the organization’s commitment to continuous improvement. Select requirements that can be monitored, measured, and improved over time to enhance the effectiveness of the ISMS.
  9. Documentation and Communication: Clearly document the selected requirements and the rationale for their inclusion in the ISMS. Communicate these decisions to relevant stakeholders, including employees, customers, and partners.
  10. Review and Update: Establish a regular review process to reassess the relevance and effectiveness of the selected requirements. Information security threats and organizational contexts evolve, so periodic reviews are essential for maintaining alignment.
  11. Alignment with Industry Standards: Ensure that the selected requirements align with industry standards and best practices for information security. This alignment can provide a solid foundation for the organization’s security measures.
  12. Demonstrate Compliance: Select requirements that can be effectively demonstrated and audited to showcase the organization’s compliance with information security standards and regulations.

By carefully considering these factors, an organization can make informed decisions on which requirements to prioritize and address through its ISMS. This ensures that the information security controls are tailored to meet the specific needs of the organization and its stakeholders.

Let’s take an example to illustrate how an organization might address specific requirements through its Information Security Management System (ISMS). Suppose one of the identified requirements is related to the confidentiality of customer data. Here’s how the organization could address this requirement through its ISMS:

  1. Requirement: Confidentiality of Customer DataSteps to Address through ISMS:
  2. a. Risk Assessment:
    • Conduct a risk assessment to identify potential threats and vulnerabilities to the confidentiality of customer data.
    b. Policy Development:
    • Develop an Information Security Policy that explicitly addresses the confidentiality of customer data. The policy should define the scope, responsibilities, and principles for safeguarding this information.
    c. Access Controls:
    • Implement access controls within the ISMS to restrict access to customer data only to authorized personnel. This may include role-based access, strong authentication, and encryption.
    d. Employee Training:
    • Integrate employee training programs within the ISMS to raise awareness about the importance of maintaining the confidentiality of customer data. This training could be part of the overall security awareness program.
    e. Data Classification:
    • Implement a data classification system within the ISMS to categorize information, including customer data, based on its sensitivity. Apply appropriate security controls based on the classification.
    f. Encryption:
    • Incorporate encryption mechanisms within the ISMS to protect customer data during storage, transmission, and processing. This could involve the use of encryption algorithms and protocols.
    g. Incident Response Plan:
    • Develop an incident response plan within the ISMS to address potential breaches of confidentiality. Define procedures for reporting and responding to incidents that may compromise customer data.
    h. Monitoring and Auditing:
    • Implement monitoring and auditing mechanisms within the ISMS to track access to customer data, detect anomalies, and ensure compliance with established security controls.
    i. Compliance Documentation:
    • Document the measures taken to ensure the confidentiality of customer data within the ISMS. This documentation may include policies, procedures, risk assessments, and audit reports.
    j. Regular Review and Improvement:
    • Establish a process for regularly reviewing the effectiveness of the measures implemented. Use feedback, audit results, and incident reports to continuously improve the ISMS and its ability to maintain the confidentiality of customer data.

This example illustrates how specific requirements, in this case, the confidentiality of customer data, can be systematically addressed through various components of an ISMS. The organization, in alignment with its overall information security objectives, implements a range of measures that are documented, monitored, and subject to continuous improvement. This approach helps the organization meet stakeholder expectations and regulatory requirements while fostering a robust security posture.

The requirements of interested parties can include legal and regulatory requirements and contractual obligations

legal and regulatory requirements, as well as contractual obligations, are often critical components of the requirements identified by interested parties in the context of an Information Security Management System (ISMS). Addressing these requirements is crucial for ensuring compliance, managing risks, and meeting the expectations of relevant stakeholders. Let’s delve into each of these:

  1. Legal and Regulatory Requirements:
    • Example: Suppose the organization operates in the European Union. In this case, compliance with the General Data Protection Regulation (GDPR) would be a legal requirement. The organization needs to ensure that its ISMS addresses GDPR principles related to the processing and protection of personal data.
    • Addressing through ISMS:
      • Implement controls and processes within the ISMS to ensure compliance with specific legal requirements.
      • Regularly monitor changes in relevant laws and regulations and update the ISMS accordingly.
      • Document compliance measures and maintain records for audit purposes.
  2. Contractual Obligations:
    • Example: The organization has contractual agreements with clients that specify certain security measures, such as encryption of sensitive data. These contractual obligations must be met to maintain trust and legal standing.
    • Addressing through ISMS:
      • Include a review of contractual obligations in the risk assessment process of the ISMS.
      • Develop specific policies and procedures within the ISMS to address contractual security requirements.
      • Establish a mechanism to communicate and coordinate with relevant departments to ensure adherence to contractual obligations.
  3. Compliance Verification:
    • Example: A business partner may require evidence of compliance with a specific security standard, such as ISO/IEC 27001. Providing this evidence is essential for maintaining a trusted relationship.
    • Addressing through ISMS:
      • Incorporate processes for verifying and documenting compliance with relevant standards within the ISMS.
      • Establish a communication mechanism to provide evidence of compliance to partners as needed.
  4. Data Protection Laws:
    • Example: A new data protection law is enacted in the region where the organization operates, imposing additional requirements on the handling of personal data.
    • Addressing through ISMS:
      • Regularly update policies and procedures within the ISMS to align with changes in data protection laws.
      • Conduct training sessions for employees to ensure awareness of new legal requirements.
  5. Industry-Specific Regulations:
    • Example: Organizations in the healthcare sector may be subject to regulations such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States.
    • Addressing through ISMS:
      • Develop and maintain controls within the ISMS that specifically address industry-specific regulations.
      • Conduct regular assessments to ensure ongoing compliance with industry regulations.
  6. Audit and Reporting Requirements:
    • Example: Regulatory bodies may require regular audits and reports on the organization’s information security practices.
    • Addressing through ISMS:
      • Establish processes within the ISMS to facilitate internal and external audits.
      • Develop reporting mechanisms to provide required information to regulatory bodies.

Addressing legal, regulatory, and contractual requirements within the ISMS ensures that the organization not only complies with applicable laws and agreements but also builds a robust and resilient information security framework that can adapt to changing requirements over time. This integration contributes to the overall effectiveness of the ISMS in managing information security risks and meeting the expectations of interested parties.

ISO 27001:2022 Clause 4.1 Understanding the organization and its context

ISO 27001:2022 Requirements
The organization shall determine external and internal issues that are relevant to its purpose and that affect its ability to achieve the intended outcome of its information security management system.
NOTE Determining these issues refers to establishing the external and internal context of the organization considered in Clause 5.4.1 of ISO 31000: 2018.

Clause 4.1 of ISO 27001 focuses on understanding the organization and its context. This clause is an essential part of the standard because it sets the foundation for developing an effective information security management system. The purpose of this clause is to ensure that the organization establishes and maintains an understanding of its internal and external context relevant to the information security management system (ISMS).

  1. Understanding the Organization: Identify the internal and external issues that can impact the organization’s ability to achieve its intended outcomes. Consider factors such as the organization’s mission, vision, values, culture, structure, and activities.
  2. Understanding the External Context: Identify external parties (interested parties) and the relevant requirements that can affect the ISMS. Examples of external parties include customers, suppliers, regulatory bodies, and other stakeholders.
  3. Understanding the Internal Context: Identify the internal factors that can influence the organization’s ability to achieve its information security objectives. This includes the organization’s structure, roles, responsibilities, policies, processes, and resources.
  4. Documented Information: Maintain documented information on the organization’s context.

Implementation Steps:

  1. Define the Scope: Clearly define the scope of the ISMS, outlining the boundaries and applicability of the system within the organization.
  2. Conduct a Context Analysis: Conduct an analysis to identify internal and external factors that may impact information security. This may involve SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis.
  3. Identify Interested Parties: Identify and understand the needs and expectations of interested parties relevant to information security. Consider customers, suppliers, employees, regulatory bodies, and other stakeholders.
  4. Maintain Documented Information: Document the information related to the organization’s context. This documentation could include policies, procedures, or other relevant records.

Benefits:

  1. Informed Decision-Making: A thorough understanding of the organization’s context helps in making informed decisions regarding information security.
  2. Risk Assessment: It provides a foundation for conducting a risk assessment by identifying internal and external factors that may pose risks.
  3. Alignment with Objectives: Ensures that the ISMS is aligned with the organization’s overall objectives and strategic direction.
  4. Compliance: Helps in identifying and addressing legal, regulatory, and contractual requirements related to information security.

By addressing Clause 4.1, organizations can establish a solid foundation for developing and implementing an effective ISMS that aligns with their business objectives and the needs of relevant stakeholders.

The organization shall determine external and internal issues that are relevant to its purpose and that affect its ability to achieve the intended outcome of its information security management system. Organizations are expected to systematically determine both external and internal issues that are relevant to their purpose and that can impact their ability to achieve the intended outcomes of their information security management system (ISMS). Let’s break down this requirement:

  1. External Issues:
    • External issues refer to factors outside the organization’s boundaries that can affect its information security management system. This may include:
      • Regulatory changes and compliance requirements.
      • Technological advancements.
      • Economic conditions.
      • Market competition.
      • Stakeholder expectations.
      • Emerging security threats and vulnerabilities.
  2. Internal Issues:
    • Internal issues pertain to factors within the organization that can influence its information security management. This may include:
      • Organizational structure.
      • Corporate culture.
      • Resources (human, financial, technological).
      • Processes and procedures.
      • Previous incidents or security breaches.
      • Management commitment to security.
  3. Relevance to Purpose: The organization needs to assess the relevance of these issues to its purpose. This involves understanding how these issues may impact the achievement of the intended outcomes of the ISMS.
  4. Documentation:The organization is required to document this understanding. This documentation serves as evidence of the organization’s awareness and consideration of the external and internal issues.
  5. Strategic Alignment:The identification of these issues helps ensure that the ISMS is aligned with the organization’s strategic direction and business objectives.

By systematically determining and assessing these issues, organizations are better equipped to make informed decisions regarding the design, implementation, and improvement of their information security management systems. This process also lays the groundwork for subsequent activities in the ISMS, such as risk assessment and treatment, which are critical components of managing information security effectively.

Examples of internal issues affecting the intended outcome of an information security management system

Internal issues that can affect the intended outcome of an Information Security Management System (ISMS) are diverse and may vary depending on the nature, size, and structure of the organization. Here are some examples of internal issues that could impact the effectiveness of an ISMS:

  1. Organizational Culture: The prevailing culture within the organization, such as the attitude towards security, awareness among employees, and the importance placed on information security, can significantly influence the success of the ISMS.
  2. Resource Availability: Inadequate resources, including financial, human, and technological resources, can impact the organization’s ability to implement and maintain effective security measures.
  3. Employee Training and Awareness: Lack of training and awareness among employees about information security policies and procedures may lead to unintentional security breaches.
  4. Information Security Policies: If information security policies are not clearly defined, communicated, or enforced, employees may not adhere to security practices, increasing the risk of incidents.
  5. Technology Infrastructure: Outdated or insufficient technology infrastructure may expose vulnerabilities and make it challenging to implement robust security controls.
  6. Access Controls and Permissions: Inadequate management of user access controls, permissions, and authentication mechanisms can lead to unauthorized access to sensitive information.
  7. Incident Response Capability: The organization’s ability to effectively detect, respond to, and recover from security incidents can impact the outcome of the ISMS.
  8. Vendor and Supply Chain Security: Weaknesses in the security practices of vendors or partners in the supply chain can introduce risks to the organization’s information security.
  9. Change Management Processes: Inadequate change management processes can lead to unauthorized changes in the information systems, potentially introducing security vulnerabilities.
  10. Communication and Collaboration: Poor communication and collaboration between different departments or teams within the organization may hinder the implementation of a cohesive and effective ISMS.
  11. Management Commitment: Lack of commitment and support from top management may result in insufficient resources and attention allocated to information security initiatives.
  12. Monitoring and Review Processes: Ineffective monitoring and review processes may prevent the organization from identifying and addressing security weaknesses or evolving threats.
  13. Documented Information Management: Poor management of documented information, including policies, procedures, and records, can hinder the organization’s ability to maintain a structured ISMS.
  14. Insufficient Training and Skillsets: If staff lacks the necessary training and skills in information security, they may struggle to implement and maintain security measures effectively.
  15. Information as assets that are internal issues affecting ISMS outcomes:What information is created, handled, stored, managed and of real value for the organisation and its interested parties such as Personal data, sensitive customer ideas and IPR, financial information, brand, codebases etc.This is right at the heart of the ISMS where the information assets are the foundation for everything else – identifying these assets early on also makes the information asset inventory management easy .Then consider potential issues around the information itself – in particular confidentiality, integrity and availability, taking into account the other areas below as you go for triggering ideas of where the issues might be found.
  16. People related internal issues that might affect the intended outcome of the ISMS: Human resource security is an important part of the ISMS, Therefore consider any existing issues of:
    • recruitment e.g. challenges in hiring competent people, high/low staff turnover
    • Induction – e.g. do they get training on information security right now, is it working in life management e.g. keeping them engaged and showing their compliance to the policies and controls, – do staff actually find information security sexy and exciting or is it a cultural challenge to get someone to lock their laptop when going to the toilet
    • change of roles and exit e.g. is access to and removal of information assets and services carried out
  17. Organisational internal issues affecting ISMS outcomes:What are the issues facing the organisation that might affect the outcome of the ISMS? As an example, fast growth brings issues of staff and structure that might affect understanding and knowledge of the policies, or that things change so quickly you can’t easily bottom out detailed and consistent processes. Are there organisation leadership and board or shareholder pressures that will cause issues (these can be positive as well as negative)? International operations will have different cultural norms for the people involved. Another internal issue associated to people and the organisation might be about the fact you don’t want many of them employed or struggle to find good ones so rely instead on outsourcing. That brings a need for suppliers (and staff in the suppliers) so that’s an issue to tie in with the interested parties analysis you’ll do in 4.2 next.
  18. Products & Services internal issues that might impact the ISMS outcomes:What are the products and services delivered by the organisation and what sort of issues emerge around that which might cause information risk? For example, if the organisation is an innovator and IPR protection is important for product leadership, it’s an issue that needs consideration in the ISMS. If the organisation relies on large physical property e.g. as a manufacturer that will probably bring more physical security issues, whereas a small cloud software provider might be much more focused on issues like IPR protection from digital hackers and the issues surrounding dependency of their product success and assurance on hosting suppliers etc.
  19. Systems and Processes as internal issues that affect the intended outcome of the ISMS: People often think about computers and digital technology when the ‘system’ word is used. However manual and paper-based systems are also key areas for issues to emerge so remember to consider those for issues too. Each of the areas bucketed above will have systems and processes involved in it – that might be implicit (we have always done it that way and never documented it) or could be wrapped up in a mass of documentation that no one could ever follow. An issue is that you might be hiring people that are going to become the enemy within….either through ignorance of information security or because they are a saboteur and you never considered that…….Its the same with all the systems and processes across the organisation that are in scope for information assurance – what sort of issues emerge where confidentiality, integrity or availability of the information might be at threat? It’s crucial for organizations to assess their unique internal issues and tailor their ISMS to address these challenges effectively. Regular reviews and updates to the ISMS help ensure that it remains aligned with the organization’s internal context and continues to effectively manage information security risks.

Examples of external issues affecting the intended outcome of an information security management system

External issues can have a significant impact on the effectiveness of an Information Security Management System (ISMS). Organizations need to consider factors beyond their immediate control that may influence the security of their information assets. Here are examples of external issues that can affect the intended outcome of an ISMS:

  1. Regulatory Changes: Changes in laws and regulations related to information security, data protection, and privacy can create new compliance requirements that organizations need to address.
  2. Industry Standards and Best Practices: Evolving industry standards and best practices may necessitate updates to the organization’s security controls to remain in line with current benchmarks.
  3. Technological Advances: Rapid technological advancements can introduce new security threats and vulnerabilities, requiring the organization to adapt its security measures accordingly.
  4. Cybersecurity Threat Landscape: The constantly changing landscape of cybersecurity threats, including new types of malware, hacking techniques, and social engineering tactics, can impact the organization’s risk profile.
  5. Global Events and Geopolitical Risks: Geopolitical events, natural disasters, or global incidents can disrupt operations and introduce new risks that organizations need to consider in their ISMS.
  6. Supplier and Third-Party Risks: Security vulnerabilities within the supply chain or third-party services can pose a risk to the organization’s information security.
  7. Economic Conditions: Economic factors such as recessions or financial instability may impact the organization’s ability to allocate resources to information security initiatives.
  8. Public Perception and Reputation: Security incidents affecting similar organizations can impact public perception and the reputation of the organization, influencing customer trust and confidence.
  9. Emerging Technologies: The adoption of new technologies, such as cloud computing or Internet of Things (IoT), introduces new security considerations that need to be addressed in the ISMS.
  10. Legal and Contractual Requirements: Changes in legal or contractual requirements, including the introduction of new data protection obligations, can affect the organization’s information security practices.
  11. Social and Cultural Factors: Social and cultural shifts, including changes in user behavior and expectations, can influence the way organizations need to approach information security.
  12. Competitive Landscape: Actions taken by competitors or industry peers to enhance or neglect their information security may impact the organization’s competitive position.
  13. Availability of Security Solutions: The availability and effectiveness of security solutions, such as antivirus software or intrusion detection systems, may influence the organization’s ability to implement effective controls.
  14. Globalization: Operating in a global market introduces additional challenges related to different legal frameworks, cultural norms, and geopolitical considerations.
  15. Media and Public Relations: Media coverage of security incidents or breaches, even if unrelated to the organization, can shape public perception and impact the organization’s operations.
  16. Political external issues affecting the outcomes from an ISMS: What political issues might affect the organisation and affect outcomes? Examples could include specific policy changes in a sector that impact investment or growth that might lead to different ways of working, and different approaches to information management.
  17. Economic external issues affecting the outcomes from an ISMS:How does the economics of your market and the supply chain impact the organisation? Does that lead to more or less issues with suppliers, customers, what information security corners might get cut in a cost reduction arena and lead to increased risk or threat (and of course opportunity too)?Examples might be cheaper labour, less training and less time for doing the work, or inability to afford decent technological systems that would help improve operations because funds need to be prioritised elsewhere
  18. Sociological external issues affecting the outcomes from an ISMS: How is society or your audience demographic changing and affecting your business – for example always on connected citizens offer opportunity and threat, and a generation of staff that sometimes have more/less regard for data brings positives and negatives too.
  19. Technological external issues affecting the outcomes from an ISMS: How does the increasing pace of technological change create issues for the ISMS outcomes? Daily changes in operating systems being patched versus (say) once a year in the past? That leads to a need for much more dynamic management that many organisations struggle to maintain which, if left unmanaged, increases the threat of a cyber breach and loss becomes more likely.Where does artificial intelligence, machine learning, cloud, and every other technological buzzword create issues for your organisation externally?
  20. Legislative external issues affecting the outcomes from an ISMS:One of the most common areas of failure in ISO 27001 is the inability to effectively highlight awareness of and then manage application legislation and regulation issues.  It goes way beyond data protection, legal requirement, computer monitoring, human rights and intellectual property law, so do give this area serious consideration for any information in your scope. You won’t necessarily need a lawyer but showing you have considered the applicable legislation affecting the organisation will make risk treatment, policy & control creation more focused and relevant as well.It might be that your risk appetite for something is quite high but if an applicable legislation or regulation sets the bar, then you’ll need to develop policies and controls for complying with that rather than just what you might think is okay!

Conduct a Context Analysis

Conducting a context analysis is a critical step in understanding the internal and external factors that can impact the effectiveness of an Information Security Management System (ISMS). Here’s a general guide on how to conduct a context analysis:

  1. Define the Scope: Clearly define the scope of your ISMS. Identify the boundaries and context within which your organization’s information security is intended to operate. Consider the locations, assets, processes, and systems included in the scope.
  2. Identify Interested Parties: Identify and list the interested parties or stakeholders relevant to your ISMS. This can include employees, customers, suppliers, regulatory bodies, and others with an interest in your information security practices.
  3. External Analysis: Identify external factors that can affect your ISMS. This may involve a review of:
    • Legal and Regulatory Environment: Assess the legal and regulatory requirements related to information security in the regions where you operate.
    • Industry Standards and Best Practices: Consider relevant industry standards and best practices that may impact your security controls.
    • Economic Conditions: Evaluate economic factors that may affect resource allocation for information security.
    • Technological Trends: Stay informed about technological advancements and emerging threats.
  4. Internal Analysis: Identify internal factors that may influence your ISMS. This includes:
    • Organizational Structure: Understand how the organizational structure may impact information security responsibilities and communication.
    • Corporate Culture: Assess the organization’s culture and its attitude towards information security.
    • Resources: Evaluate the availability of resources, including human, financial, and technological resources.
    • Processes and Procedures: Review existing processes and procedures related to information security.
    • Previous Incidents: Learn from past incidents or security breaches to identify areas for improvement.
  5. SWOT Analysis: Conduct a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis based on the information gathered. This can help you identify internal and external factors that may positively or negatively impact your ISMS.
  6. Risk Assessment: Use the information gathered to perform a preliminary risk assessment. Identify potential risks and their likelihood and impact on the organization’s information security objectives.
  7. Document the Analysis: Document the findings of your context analysis. Create a document that summarizes the identified internal and external issues, interested parties, and the results of your SWOT analysis.
  8. Review and Update:Periodically review and update your context analysis. The business environment and threat landscape are dynamic, so it’s important to revisit your analysis to ensure it remains relevant.
  9. Integration with ISMS:Ensure that the insights gained from the context analysis are integrated into the development and implementation of your ISMS. Use this information to inform the setting of information security objectives, controls, and risk management strategies.
  10. Management Review:Present the results of the context analysis during management review meetings. Seek management input and validation to ensure alignment with organizational goals.

By systematically conducting a context analysis, organizations can gain valuable insights into the factors that shape their information security landscape. This, in turn, allows for the development of a more effective and tailored ISMS that aligns with the organization’s strategic objectives.

Example of Context analysis

Let’s consider a hypothetical organization, XYZ Corporation, and walk through an example of a context analysis for their Information Security Management System (ISMS):

1. Define the Scope:

  • Scope of ISMS: XYZ Corporation operates globally and manages sensitive customer information, financial data, and proprietary business processes. The ISMS scope includes all departments, systems, and processes that handle or support the handling of sensitive information.

2. Identify Interested Parties:

  • Stakeholders:
    • Employees
    • Customers
    • Shareholders
    • Regulatory Authorities
    • Third-party vendors

3. External Analysis:

  • Legal and Regulatory Environment:
    • Compliance with GDPR, HIPAA, and industry-specific regulations.
    • Changes in data protection laws globally.
  • Industry Standards and Best Practices:
    • Adherence to ISO 27001 standards.
    • Following NIST Cybersecurity Framework.
  • Economic Conditions:
    • Budget constraints affecting resource allocation for information security initiatives.
  • Technological Trends:
    • Increasing reliance on cloud services.
    • Growing use of Internet of Things (IoT) devices.

4. Internal Analysis:

  • Organizational Structure:
    • Decentralized structure with regional offices.
    • Dedicated information security team reporting to the CISO.
  • Corporate Culture:
    • Emphasis on innovation and collaboration.
    • High awareness of cybersecurity among employees.
  • Resources:
    • Sufficient budget allocated to information security.
    • Adequate staffing for the information security team.
  • Processes and Procedures:
    • Documented incident response and business continuity plans.
    • Periodic security training for employees.
  • Previous Incidents:
    • Analysis of past incidents led to the improvement of access controls.
    • Lessons learned from a data breach incident resulted in enhancing encryption practices.

5. SWOT Analysis:

  • Strengths:
    • Strong commitment to information security.
    • Experienced information security team.
  • Weaknesses:
    • Reliance on a single cloud service provider.
    • Limited integration between IT and physical security systems.
  • Opportunities:
    • Embracing emerging technologies for improved security.
    • Collaborating with industry peers for threat intelligence sharing.
  • Threats:
    • Increasing sophistication of cyber threats.
    • Potential legal and financial consequences of non-compliance.

6. Risk Assessment:

  • Identified high-risk areas:
    • Dependence on a single cloud service provider.
    • Rapid adoption of emerging technologies without thorough security assessment.

7. Document the Analysis:

  • Create a document summarizing the context analysis, including an overview of external and internal factors, interested parties, and the results of the SWOT analysis.

8. Review and Update:

  • Periodically review and update the context analysis, especially when there are significant changes in the organization’s environment or the information security landscape.

9. Integration with ISMS:

  • Use the insights gained from the context analysis to inform the development of information security objectives, controls, and risk management strategies within the ISMS.

10. Management Review:

  • Present the results of the context analysis during management review meetings to ensure alignment with organizational goals and gain management input and support.

This example illustrates how a context analysis provides a comprehensive understanding of the internal and external factors that can influence the effectiveness of an organization’s ISMS. It forms the foundation for making informed decisions and developing a robust and tailored information security program.

Determining these issues refers to establishing the external and internal context of the organization considered in Clause 5.4.1 of ISO 31000:2018

ISO 31000 indeed emphasizes the importance of determining the internal and external context as part of the risk management process. This aligns with the broader understanding of organizational context in management system standards, including ISO 27001. The following methodology of ISO 31000:2018 can be used to establish the context for ISO 27001

ISO 31000:2018 Clause 5.4.1 – Establishing the Context:

  1. Scope and Objectives: Clearly define the scope of the risk management process and establish the context by stating the objectives that the organization wants to achieve through risk management.
  2. Internal Context: Identify the internal factors that can influence the achievement of objectives. This includes factors such as the governance structure, policies, culture, capabilities, and resources of the organization.
  3. External Context: Identify the external factors that can impact the achievement of objectives. External context includes legal, regulatory, technological, market, and environmental factors, among others.
  4. Stakeholders: Identify and consider the needs and expectations of stakeholders. Understanding the perspectives of stakeholders is crucial in assessing and managing risks effectively.
  5. Risk Criteria: Establish the criteria against which risks will be evaluated. This includes considering factors such as the organization’s risk appetite, tolerance, and criteria for assessing the significance of risks.
  6. Assumptions and Constraints: Identify any assumptions made and constraints that may impact the risk management process. Assumptions and constraints should be considered in the context to ensure a realistic and practical approach to risk management.
  7. Information Sources: Determine the sources of information that will be used to identify and assess risks. This may include internal reports, external data, industry benchmarks, and expert opinions.
  8. Documentation: Document the established context. Documentation ensures that there is a clear and shared understanding of the context within the organization and provides a basis for consistent risk management decisions.

IATF 16949:2016 Clause 9.2.2.1 Internal audit programme

Internal audit is a tool to gauge the health of your QMS. You must have a documented procedure for your internal audit process. Your procedure must address the following control requirements:   The scope of your internal audit program must cover:  Audit of the QMS – to determine conformity to the IATF 16949 standard;  Audit of the QMS – to determine conformity to organizational requirements; Audit of QMS processes and their interaction – to determine if the QMS has been effectively implemented and maintained;Audit of each manufacturing process to determine its effectiveness; Audit of product across all stages of production and delivery- to determine conformity to requirements specified by the customer and regulatory bodies. All shifts involved in activities affecting product or process quality. Note that there may be shifts for manufacturing processes as well as support processes.   You must adjust the audit frequency (and perhaps even the audit scope), of specific QMS processes; manufacturing processes; shifts; and products when:

  • You experience internal or external nonconformities 
  • Get customer complaints 
  • Have critical or high risk processes 
  • Have frequent or significant changes to processes and product 

    OEM customers may also specify the scope, frequency, criteria, responsibility, etc of internal audits. Your annual internal audit program should consider the following:

  • Input from audited area and related areas
  • Key customer oriented processes
  • Process and product performance results and expectations
  • Analysis of quality cost data
  • Capability of processes and use of statistical techniques
  • Effective and efficient implementation of processes (lean manufacturing techniques)
  • Opportunities for continual improvement
  • Relationships with customers 

Over the Certification Body’s (or Registrar) audit cycle (3 years), the CB must audit all of your organization’s processes and their applicable customer-specific requirements.  Your internal audit program should be more detailed and exhaustive than the external CB audit. With this outlook in mind, your internal audit program should consider auditing all your QMS processes at least once within the CB 3 year audit cycle (preferably once a year) and some processes more often based on the criteria covered above.  The design process (whether onsite of off-site) should be audited at least once within each consecutive 12 month period. Your internal QMS audit program should include all off-site processes and subcontract ‘sites’ that support your facility. These audits may be done by others, such as head office, sister facility or qualified subcontract auditors.Audit criteria , refers to the specific QMS policies, objectives; IATF  requirements; documentation; customer and regulatory requirements, etc., that the audit is referenced to or conducted against. Audit criteria may relate to the whole audit program as well as each individual audit. Audit methods refer to the specific techniques that auditors use to gather objective audit evidence that can be evaluated to determine conformity to audit criteria . Examples of audit methods include – interview of personnel, observation of activities; review of documents and records; etc.The qualification/training requirements may vary for the different types of audits required by this standard. You must define the minimum qualification/training requirements for internal auditors for each type of audit : 

  • Personnel performing QMS audits or manufacturing process audits must have adequate training on
    • the requirements of the IATF 16949 standard;
    • training on the automotive process to auditing;
    • audit practices and audit experience as defined by ISO 19011 and IATF guidance;
    • QMS processes and their interaction; customer requirements and applicable regulatory requirements.
  • Personnel performing product audits must have training on
    • production and delivery processes;
    • audit practices and techniques; p
    • product specific customer requirements and
    • applicable regulatory requirements.

Product specific auditors do not necessarily need training on the requirements of the TS 16949 Standard.  You must have appropriate resources to carry out your annual audit program. These include – having sufficient trained auditors available to conduct scheduled audits; sufficient time to perform audits; availability of process personnel to be audited; time and tools to prepare audit records and reports; etc.  

Auditor Independence – Auditors can audit their own department provided their objectivity and impartiality is not compromised, but they cannot audit their own work. You must ensure auditor independence when assigning personnel to specific audits.  

Process owners must take timely corrective action on nonconformities found in their area. They should use the corrective action procedure (clause 8.5.2) to determine root cause, take action and follow-up to determine if results indicate that the root cause has been eliminated.

Audit results must be summarized and reported for management review . The Management Representative must also report any opportunities for QMS improvement . The MR must analyze the results of each audit as well as the annual audit program to determine strengths and weaknesses in QMS processes, interactions, functions, products, etc., to identify and prioritize opportunities for improvement.  Audit records include – annual audit schedule; audit planning- (criteria, scope, frequency, methods, auditor selection and assignment, etc); auditor competence and training; audit checklists and forms; audit notes and other evidence gathered; audit findings; nonconformity reports; audit reports; corrective actions and follow-up of internal audit nonconformities; analysis of audit program performance indicators and trends; and identified improvement opportunities.  Like all QMS processes , you must have performance objectives (indicators) to measure the effectiveness of your internal audit process and monitor trends in these indicators, to continually improve your audit program. Performance indicators may include reducing the number of – late or delayed audits; incomplete audits; incomplete audit records and late reports; auditor errors; auditee complaints; and use of untrained auditors; etc.  T

9.2.2.1 Internal audit programme

The organization needs to establish a documented internal audit process that encompasses the entire quality management system, covering quality management system audits, manufacturing process audits, and product audits. The audits should be prioritized considering risk, internal and external performance trends, and process criticality. If the organization is involved in software development, software development capability assessments must be included in the internal audit program. Audit frequency should be periodically reviewed and adjusted based on process changes, nonconformities, and customer complaints. The effectiveness of the audit program should be evaluated as part of management review.

The standard requires the supplier to establish and maintain documented process for planning and implementing internal quality audits. The standard requires process for both planning and implementing audits and these should cover the following:

  • Preparing the annual audit program
  • The selection of auditors and team leader if necessary
  • Planning audits Of each type
  • Conducting the audit
  • Recording observations
  • Determining corrective actions
  • Reporting audit findings
  • Implementing corrective actions
  • Confirming the effectiveness of corrective actions
  • The forms on which you plan the audit
  • The forms on which you record the observations and corrective actions
  • Any warning notices you send out of impending audits, overdue corrective actions,
    escalation actions

Certain activities such as the opening and closing meeting have been omitted for clarity because they are not always needed for internal audits. The product audit process would be somewhat different but the principles would be the same. There audits should be comprehensive and there is a need to ensure that the audit program covers all aspects of the quality system in all areas where it is to be employed. The coverage of the audit program should be designed so that it obtains sufficient confidence in operations to be able to declare that the system is effective. There may be a need for different types of audit programs depending on whether the audits are of the quality system, processes, products, or services. The audit program should be presented as a calendar chart showing where and when the audits will take place. All audits should be conducted against a standard for the performance being measured. Examinations without such a standard are surveys, not audits. Audits can also be conducted against contracts, project plans, specifications — in fact any document with which the organization has declared it will comply. The standard now requires system audits to be conducted to verify compliance with IATF 16949 and any other system requirements. In order to ensure that your audit program is comprehensive you will need to draw up a matrix showing what policies, procedures, standards, etc. apply to which areas of the organization. The program also has to include shift working so your auditors need to be very flexible.

Internal audit for entire Quality management system

Developing and implementing an internal audit program for the entire quality management system, including quality management system audits, manufacturing process audits, and product audits, is a crucial step in ensuring that an organization maintains a high level of quality and compliance. Define the scope of the internal audit program, which should cover all aspects of the quality management system, including manufacturing processes and products. Clearly outline the objectives of each type of audit, such as ensuring compliance with regulations, identifying process improvements, and verifying product quality. Assemble a team of skilled and knowledgeable individuals from different departments who will conduct the internal audits. The team should include personnel who are independent from the areas being audited. Develop audit criteria and checklists based on applicable standards, regulations, company policies, and industry best practices. These will serve as guidelines for the auditors during the assessment process. Develop an audit schedule, identifying the frequency and timing of audits for different areas of the quality management system. Prioritize high-risk areas and critical processes for more frequent audits. Perform the internal audits according to the established schedule and using the criteria and checklists. The audit team should conduct interviews, review documentation, observe processes, and collect objective evidence to assess compliance and effectiveness. During the audits, document any non-conformities or deviations from the established criteria. Also, identify opportunities for improvement in processes or products. Prepare detailed audit reports that clearly outline the findings, including both positive aspects and areas for improvement. Communicate the results to the relevant stakeholders, such as process owners and management. Work with the respective departments to develop and implement corrective actions for identified non-conformities. Ensure that appropriate actions are taken to address the issues raised during the audits. Follow up on the implementation and effectiveness of the corrective actions. Use the findings from the internal audits to drive continuous improvement in the quality management system. Identify systemic issues and develop plans to address them. Regularly present the results of the internal audit program to top management during management review meetings. Seek feedback and support from management in addressing identified issues and improving the quality management system. Provide training to the audit team to enhance their auditing skills and knowledge. Ensure that auditors are competent and up-to-date with relevant regulations and standards. Continuously monitor the effectiveness of the internal audit program and make adjustments as necessary. Keep the program up-to-date with changes in regulations, company processes, and best practices.By following this process, an organization can ensure that its internal audit program contributes to the improvement of the quality management system, manufacturing processes, and product quality, ultimately leading to enhanced overall performance and customer satisfaction.

Prioritizing the audit program

Prioritizing the audit program based on risk, internal and external performance trends, and criticality of the processes is a strategic approach to ensure that resources are allocated effectively and that audits focus on the areas that have the most significant impact on the organization. Conduct a comprehensive risk assessment of the organization’s processes, products, and quality management system. Identify areas with the highest risks, such as those that could lead to safety hazards, compliance violations, or significant financial losses. Allocate more frequent and thorough audits to high-risk areas. Analyze internal performance data and metrics to identify trends and areas of concern. This could include data on customer complaints, product defects, process deviations, and internal non-conformities. Focus audits on areas that consistently show performance issues or have experienced recent declines in performance. Monitor external performance data, including customer feedback, industry benchmarks, and regulatory compliance reports. Identify any external indicators of potential problems and include relevant areas in the audit program. Determine the criticality of each process within the organization. Critical processes are those that have a significant impact on the overall quality of products or services, customer satisfaction, or regulatory compliance. Prioritize audits for critical processes to ensure they are functioning optimally. Seek input from top management and relevant stakeholders to understand their concerns and priorities. Take into account their perspectives when prioritizing audits, as they may have insights into critical areas that require attention. Ensure that audits are scheduled to meet regulatory and certification requirements. Prioritize audits that are necessary for maintaining compliance with relevant standards and regulations. Consider the availability of resources, including personnel and time, when setting the audit schedule. Optimize the use of resources by aligning them with the areas of highest priority. Assess the potential impact of conducting audits on risk mitigation and improvement opportunities. Prioritize audits that offer opportunities for significant improvement and efficiency gains. Adjust the frequency of audits based on the factors mentioned above. High-risk areas or critical processes may require more frequent audits to ensure continuous monitoring and improvement. Continuously review and adapt the audit program based on the changing risk landscape and performance trends. Flexibility is crucial to respond to emerging issues and new priorities.By employing this prioritization approach, the organization can focus its internal audit efforts on areas that matter most, resulting in a more effective and efficient audit program that contributes significantly to the improvement of the quality management system and overall organizational performance.

Including software development capability assessments in audit program

Including software development capability assessments in the organization’s internal audit program is crucial for several reasons. As the organization is responsible for software development, ensuring the effectiveness and maturity of its software development processes is paramount to delivering high-quality software products and maintaining a competitive edge in the market. By conducting software development capability assessments, the organization can evaluate the efficiency and compliance of its development practices, identify areas of improvement, and mitigate potential risks.Firstly, software development capability assessments enable the organization to gauge the proficiency of its development teams and processes. It helps in assessing whether the teams possess the necessary skills, tools, and resources to carry out their tasks effectively. By identifying any gaps or deficiencies, the organization can invest in targeted training and development initiatives, thus enhancing the overall competency of its software development workforce.Secondly, these assessments contribute to the improvement of software development processes. By evaluating the software development lifecycle, code quality, and adherence to best practices, the organization can identify bottlenecks and inefficiencies. This empowers them to implement process improvements, streamline workflows, and adopt industry-standard methodologies, leading to faster delivery cycles and higher-quality software.Thirdly, software development capability assessments assist in ensuring compliance with relevant standards and regulations. Regular assessments help in verifying compliance, mitigating potential legal and financial risks, and building trust with customers and stakeholders.Moreover, these assessments provide valuable insights into the security and reliability of the software being developed. By conducting code reviews, vulnerability assessments, and security audits, the organization can proactively identify and address security flaws before software products are deployed to customers.Ultimately, integrating software development capability assessments into the internal audit program reinforces the organization’s commitment to continuous improvement. It fosters a culture of quality, innovation, and risk management within the development teams, enabling the organization to deliver cutting-edge software solutions that meet customer expectations and drive business success.

Review in MRM

Reviewing the effectiveness of the audit program as part of the management review is a critical aspect of maintaining a robust and successful internal audit process. The management review is a strategic and high-level meeting where top management assesses the overall performance of the organization, including its quality management system and related processes. By including the audit program in the management review, the organization ensures that audits are aligned with the company’s objectives and contribute effectively to continuous improvement. The audit program’s effectiveness is evaluated during the management review to determine how well it is achieving its intended goals. This includes assessing whether the audit program is identifying areas of non-conformity, opportunities for improvement, and whether corrective actions are being implemented in a timely manner. Management review provides an opportunity to assess whether the resources allocated to the audit program, such as personnel, time, and tools, are adequate and properly utilized. Any adjustments needed to optimize resource allocation can be addressed during this review. The management review allows the organization to analyze whether the audit program adequately addresses high-risk areas identified in the risk assessment. It ensures that the most critical processes and areas are audited more frequently and with greater rigor. Top management can review the audit program’s performance in meeting regulatory requirements and industry standards. This helps to ensure that the organization remains compliant with relevant regulations and maintains any necessary certifications. Management review provides insights into how the audit program contributes to the organization’s overall improvement efforts. It helps identify areas where the audit process can be enhanced, and it ensures that audit findings are used effectively to drive positive change.Management review includes an assessment of the effectiveness of corrective actions taken in response to audit findings. This ensures that identified issues are adequately addressed and that improvements are sustained over time. Reviewing the audit program during management review allows top management to hold responsible parties accountable for the execution and outcomes of audits. It encourages open communication and commitment to the audit process across the organization. By integrating the audit program into the management review, the organization ensures that audits are aligned with its strategic objectives. It helps focus audits on areas that have the most significant impact on achieving organizational goals.

ISO 27001:2022 Example of Setting and Monitoring of Information security Objectives

1.0 Objective :

To define a System for setting of Information Security Objectives/Key Performance Indicators (KPIs) and monitoring them for achievement.

2.0 Scope :    

Relates to Objectives/KPIs related to Information Security for all the key functions of  XXX

3.0 Responsibility:   

  • CISO     
  • Department Heads

4.0     Procedure:

Setting of Objectives /Key Performance Indicators

Management of XXX shall set yearly Information Security Objectives/KPIs for all the Departments . Department Heads  sets own objectives  based upon the risk assessment . The Information security objectives /KPIs fall into 5  broad  categories :

  1. IT and business alignment
  2. Information security risk management process
  3. Compliance processes
  4. Awareness process
  5. Audit processes

            It is ensured that the Objectives are in line with the Corporate policy for Information Security Management.

   Information Security  Objectives  for departments

The Department Head of each section/department sets up Information Security Objectives  and are communicated to all the key members of the team. Defined objectives cover:

  •  Measurable targets
  • Time frame to achieve the targets 
  • Plan of action for achievement of the Objectives.

Monitoring of Objectives

Monitoring of  Objectives  is done by Department Heads  and the frequency of review is set by the  Department Head , for each objective / KPI and  are usually half-yearly. The achievement of Objectives is reviewed on a six monthly basis and are recorded in the Objectives Review Report . The objectives review details are consolidated and discussed in the Management Review Meeting attended by the higher Management.

5.0 Records:

  1. Objectives and their Review Records  ( F-08)
  2. Management Review Meeting Minutes. ( F-10)

 6.0 References:  

     Nil 

Example of Objective

1. IT and business alignment

ObjectiveMethod/sourcesTargetsJustificationFindingsJustificationAction plans
% of business strategic goals and requirements supported by information security strategic goals and decisions.Review business strategic decisions and ensure that they have been risk-assessed in relation to IT and information security issues. Likewise all major information security strategic decisions should be reviewed and approved by upper management to ensure alignment with business services and strategies.100%All business decisions need to be supported by IT decisions and specifically information security issues. If not relevant, this needs to be documented and approved as part of the project phase.50%Our latest outsourcing and IT procurement decisions have not been aligned with our IT strategy and specifically not with information security requirements.Ensure that IT requirements are mandatory on the agenda and all relevant information security requirements and potential issues are identified and addressed.
Level of business (stakeholders) satisfaction with offered information security services and internal support. Does information security bring value to the stakeholders?Data collected through interviews or survey forms sent to relevant stakeholder of each business unit, business process or similar.HighOur baseline is above average e.g. high level of satisfaction with offered information security services (scale going from
low over medium, high, to excellent).
HighCompared to last year we have increased the level of satisfaction from medium to high.No action plans
Percentage of executive management roles with clearly defined accountability for information security decisions.Review job roles and descriptions to ensure that responsibility and accountability has been defined and communicated.80%It’s important that management and, in particular, business unit owners and IT-systems owners have clearly defined roles and accountability. We are planning to increase the numbers from 50% to 80% this year and next year ensure 100% coverage.85%We are on target this year with 85%No action plans
% of changes to the information security strategy that is approved by management.Review current information security strategy or major information security strategic decisions and ensure that management has formally approved them.100%All information security strategic decisions need to be approved by management.75%Some IT-strategic decisions to outsource critical IT-systems during 2022 were not risk assessed or approved by management.Ensure that all major IT-strategic decisions are management approved. Establish some baseline requirements for management approval. For example:
1) Critical IT-services
2) Sensitive data?
3) Specific information security issues
4) Budgetary scope
5) Conflicts with business strategies

2. Information security risk management process

ObjectiveMethod/sourcesTargetsJustificationFindingsJustificationAction plans
% of business processes and their-services covered by the risk management process.Interviews and correlation with management.50%Depending on current maturity level of an organisation it could be all or only some of the business processes/IT-services. Extending coverage could be part of a maturity process.40%Four critical business processes have not been subjected to a BIAWe need to find out if it’s a resource problem or poor risk planning
% of approved risk treatment plans actually being
implemented compared to last risk assessment.
Correlate with previous risk assessment
reports.
100%We need to ensure that proposed and approved risk treatment plans are carried through and not forgotten or “saved for later”.60%Only 60% of the approved action plans have been implemented this year. This is a drop on 20% compared to last year.Training of risk treatment to the team. Identify the root cause for e.g. is it financial issue, lack of ownership or other factors.
Are significant organisational or technological changes being reflected in the latest risk assessment?Interview and review of risk assessment
reports.
100%All major technological shifts (IT- procurement, investments, outsourcing, etc.) need to be reflected in the IT-risk assessment.100%Our use of cloud outsourcing services and the approval of BYOD has been included in the IT-risk assessment.No action plans
% of IT budgets used to manage IT risk management processes.This requires information security spending to be documentedCorrelate total man-hours spent on risk assessment process with total IT-budget.No valueTarget could be just to track spending on IT-risk management processes. The metric doesn’t necessarily need to define a
maximum % of IT budget or information security budget.
15%Budgets and time spend on the IT-risk assessment process have increased 15% since last assessment.Further analysis needs to be done. Causes can range from:
1) Changes in the methodology
2) Resource issues
3) Increase in number of identified risks (correlate with other metrics)
Number of new threats and risks identified compared to previous risk assessment.Compare total numbers of risks/vulnerabilities, and/or criticality level with previous IT-risk assessments.0We need to reduce our risk posture and ensure that prior risks and vulnerabilities don’t reoccur.7The total number of critical risks/ vulnerabilities is slightly increasing, but the number of recurrent risks/ vulnerabilities has decreased, which indicates that we have effectively addressed prior IT-risk assessment identified risks.Further analysis needs to be done. Causes can range from:
1) Changes in the methodology
2) Resource issues
3) Increase in number of identified risks (correlate with other metrics)
Tracking changes to risk appetite. Does it increase or decrease? Can we correlate it to strategic, organisational or financial decisions?Look at changes to risk threshold. Arguments for rejections and approvals of action plans would also be a source. Correlate that with strategy changes, technology changes, security incidents, organisational changes, etc.No change Changes to risk appetite should be recorded as part of management reporting along with explanation of possible reasons.DecreaseOur risk appetite has decreased this year compared to last year.Analyse why risk appetite has changed.
Level of satisfaction with risk outcome from business perspective. This could be the risk outcome from the BIA, vulnerability assessment or action plans. The business needs to review the quality and output of the BIA to ensure data is correct.
Measurement scale: not satisfied, acceptable or very
satisfied.
Interviews or self-assessment questionnaire.Very SatisfiedWe need a high level of satisfaction (very satisfied) with the risk results from the BIA’s and vulnerability assessments.AcceptableInput from business owners, system owners and IT operations suggest that the results were not aligned with their expectations. There were too many errors in the assessments and especially in relation to the maturity assessment of IT- controls.We need to ensure that the people performing the risk assessment are adequately competent and internal review of results must be done before final reporting.

3. Compliance processes

ObjectiveMethod/sourcesTargetsJustificationFindingsJustificationAction plans
Number of non-compliance issues and derived costs per year (e.g. external requirements, policies and procedures)Reviewing end-of-year reported incidents including major external audit findings0No major non-compliance issue with either financial or image impact.1We had a data breach by our outsourcing vendorReview relevant IT-security processes and vendor contract.
Time between identification of non-compliance and implementation of fixes. Helps identify problems with the efficiency of the compliance process.Correlate time of reported non-compliance issues of security incidents with actual implementation time.0 casesDepending on the complexity, the issue needs to be addressed within two working days.2 CaseWe had two incidents that still haven’t been resolved.We need to evaluate the effectiveness of the internal compliance department. Do we need to restructure the process? Are there any resource constraints or internal opposition?
Costs for fixing non-compliance issues such as
administrative work in relation to fixing the problems
(process optimization, procedures, policies or IT controls).
Review total costs associated with fixing non-compliance with annual IT-budget.20% (max)Under normal circumstances, there is a maximum of 20% of IT-budgets allowed for addressing security related issues.more then 20% Costs relating to non-compliance issue exceed the 20% limit. This includes performing a new pen-test and reworking of policies with the assistance of external consultants.Has a business case and cost-benefit analysis been performed? Who has reviewed and approved the spending?
Total costs due to reputation loss, financial fines, loss of clients, etc.) Per compliance incident.Review total impact costs associated with compliance
issue.
0%Recording the total cost and comparing this with last year. The target is not to have an increase in costs, but a decrease.Reduction by 15%Total cost associated with this year’s compliance incidents has decreased by 15 % and there was 1 less incident.No action plans

4. Awareness process

ObjectiveMethod/sourcesTargetsJustificationFindingsJustificationAction plans
% deviation when comparing established success factors for awareness campaigns with the results of implemented campaigns.Comparing results from awareness/ training program with results of physical audits or employee quizzes/tests.80%he goal was to ensure that minimum 80% completed the test/quiz following the campaign. Physical inspection of work areas shows a significant decrease in physical sensitive work paper, unlocked workstations, USB devices, etc.60% Less than 60% answered correctly on the mobile device policies and use of cloud-services. During our internal audit, we discovered unlocked workstations and customer-sensitive documents lying in the printer room.We need to re-evaluate the way we present the message. Perhaps we can make it more story-driven and be better at using the intranet.
Are awareness plans/ strategies/sessions/courses, etc. aligned with information security risks currently of concern to the organisation?Correlate awareness/training programs and strategy with current risk posture (results from risk assessment, external requirements, security incidents, technological changes, audits, etc.).YesThere needs to be a direct link between focus-areas of awareness/training and current risk posture.NoThe awareness strategy has been arbitrarily chosen more based on security trends and media talk than actual risks
relevant to the organisation.
We need to ensure that it’s derived from relevant risks to our organisation.
% of IT users who have visited the security awareness intranet site so far this month.Document the monthly visit rate on the information security section of the intranet. 70%Our average visit rate must not fall below 70%.90%The last update with the malware alert was seen by 90% of IT-employeesNo action plans
Cost-effectiveness of the awareness and training program E.g. can we detect a reduction in security incidents with financial impact, impact to intangibles (image/reputation).Compare security incident before/ after awareness/ training efforts. This could also include physical observations of related employee behaviour, number of support calls or input from network security (IDS, IPS, content filtering or policy violations).
Other sources: Results from audits.
Decrease We must be able to detect a reduction in security incidents following our awareness/training programs.DecreaseAll approved follow-up plans have been implemented.No action plans
Retention of key awareness messages % of employees that remember awareness messages. Can be measured by doing tests/quizzes on prior awareness campaign themes.Compare results of tests performed a short time after completion to test run after a longer period of time e.g. 2- 6 month.60%Success rate of 60% of employees remembering prior awareness/training themes.less then 50%The knowledge of the topics drops dramatically after 6 months, compared to tests run after completion of awareness training.We need to maintain awareness and knowledge on important security themes by increasing the frequency of awareness initiatives.

ISO 27001:2022 Example of Procedure for continual improvement

1.0 Purpose

The purpose of this procedure is to continually improve the suitability, adequacy and effectiveness of the established ISMS. continual improvement requires measuring the effectiveness and efficiency of technology, people and processes and adapting to inevitable changes in the environment – technical, organisational or otherwise

2.0 Scope

This procedure applies to continual improvement in the ISMS for all identified processes

3.0 Responsibility:

3.1 Department/section heads: To identify the “areas of improvement” and to implement the improvement in the section after getting the approval from the Top Management.

3.2 Management representative: To remind the department/section heads/process owners about the continual improvement and request to present the status to the Top Management

3.3 CISO : To approve the continual improvement plans which may improve the Information Security management system. To ensure that there is adequate resources for the plan and to monitor the status reports from the department/ section heads/process owners.

4 Procedure:

The respective department/section heads shall identify the areas for improvement based on the policy, objectives and strategic plans of the organization. The areas of improvement shall be based on:

  • improvements in strategy (i.e. why things are done): Improving strategy improves or maintains the suitability of an ISMS and requires improving knowledge and understanding of the environment and threat landscape.
  • improvements in practice (i.e. what is done): Improving practice can increase the effectiveness of the ISMS and resulting security controls.
  • improvements in process (i.e. how things are done):Improving processes can increase the efficiency of controls and surrounding processes.

Improvements can be made in the short or long term. However most improvements will follow the process below:

  • Identify opportunity for improvement.
  • Identify root cause (as applicable).
  • Allocate responsibility for implementing change.
  • Identify, analyse and evaluate (based on cost vs benefit) possible solutions.
  • Plan implementation of changes.
  • Implement changes.
  • Measure effectiveness of actions

4.1 Steps in an improvement process

Process Example activities
1.Define what you should measureIdentify technical, operational and strategic goals
Define what you will measure
2.Define what you can measureScoping
Risk assessment and risk treatment plans
Identify the strategy for improvement
3. Gather the data
4. Process the data

Implement improvement plans
Implement controls, services monitoring etc.
5. Analyse the dataAnalyse gathered data (e.g. from monitoring)
Carry out gap analysis
Internal and external audits
6. Present and use the information
7. Implement corrective action
Implement corrective actions and fixes;
Record lessons learned
Feed back and report

The departmental/section heads shall identify and document the areas of improvement in the Continual Improvement Plan (F 012) form and send it to the management representative (MR) for review. The management representative (MR) shall review and send the plan to the CISO for final approval. Respective departmental personnel shall make prioritized action plan for the areas of continual improvement and the same shall be followed to complete the assignment in time. Respective departmental/section head shall review the status of the continual improvement plan. and the status of the plan shall be presented to the management during management review meetings. The effectiveness of continual improvement plans shall be monitored and reviewed periodically and the same shall be discussed in MRM.

4.2 Sources of information and opportunities for improvement

Opportunity for improvementSources of information
Organisational changesMeetings with top management
Departmental/organisational announcements, news bulletins etc.
Changes in business requirements/circumstancesThird party requirements
Public media and news
Security/business conferences
Team meetings
Management reviews
Service reviews
Change in security requirementsPolicy reviews
Information security incidents
Service requests
Change requests
Bulletins and announcements
Changes in regulatory environmentNotifications from suppliers
Notifications from third parties
Notification from statutory bodies e.g. the Information Commissioner’s Office
Internal security forums
Security mailing lists
Contact with Special Interest GroupsSecurity conferences and community meetings
Security mailing lists
Changes in skill setsRecruitment of new staff
Knowledge gained from training
User/customer engagementService requests
User satisfaction surveys
Knowledge bases
Service requestsService desk management tools
Knowledge bases
Risk assessmentsRisk assessment outputs
Gap analysis reports
VulnerabilitiesVendor vulnerability announcements
Security community mailing lists
Results from penetration testing and vulnerability scanning Log files
Service requests and notifications from users/customers
Information security incidentsIntrusion detection/prevention system alerts
Log files and network flows
Knowledge gained from analysing and resolving incidents
Internal audit and reviewReview meetings
Policy reviews
Audit reports
Vulnerability scanning and penetration testing reports
Security reviews
External auditsReview meetings
Audit reports
Vulnerability scanning and penetration testing reports
Security reviews

5 Reference:

Continual Improvement Plan

Example of Procedure for ISO 27001:2022 Management Review

1. SCOPE

This procedure applies to all the activities within the scope of the XXX Information System Management System.(ISO 27001:2022 )

2. PURPOSE

2.1 To ensure that top management systematically reviews the ISMS and its performance in accordance with the established operating procedures.

2.2 To review the adequacy. suitability. and effectiveness of previous corrective and preventive actions including those related to outsourced service and supplier performance.

3.3 To identify strengths and opportunities for improvement and make recommendations for continual improvement.

3. REFERENCE DOCUMENTS

3.1 XXX Information Security Management system Manual,
3.2 Procedure for Internal ISMS Audit.
3.3 Procedure for Non Conformity & Corrective Action

4. TERMS & DEFINITIONS

4.1 Management Review: cross-functional review by an organization’s top management which takes place at regular intervals aimed to assess the organization’s success at achieving objectives established thus ensuring its continued suitability, adequacy, and effectiveness and to take action to correct it when necessary.

4.2 ISMS Objective: A statement describes what should be achieved within the time frame and available resources. It shall be consistent with the evidence-based practice and the visions that the institution creates itself to achieve.

4.3 Audit: A systematic, independent, and documented process for obtaining audit evidence (records, statements of fact, or other information which are relevant and verifiable) and evaluating it objectively to determine the extent to which the audit criteria (set of policies. procedures, or requirements) are fulfilled.

5. RESPONSIBILITY AND AUTHORITY

The following will be responsible for the process of preparing for the Management Review Meeting :
5.1 CEO :
5.1.1 Assure the implementation of the MR policy
5.1.2 Chair the MR meeting
5.1.3 Invite members of the top management to the meeting
5.1.4 invite other categories of staff as per necessity (e.g. quality focal points, internal auditors)
5.2 CISO and Staff of department:
5.2.1 Set in coordination with the Director, the date and time of the meeting.
5.2.2 Prepare and present the agenda of the meeting according to the agenda stated above.
5.2.3 Take the list of attendance.
5.2.4 Make minutes of the meeting that includes discussion points raised with the suggestions as well as the decisions that have made during the output session.
5.2.5 Follow-up the decisions that have been taken during the output discussion.
5.2.6 Follow-up the implementation of the MR.

6. DETAILS OF PROCEDURE

6.1 Attendants:

6.1.1 Top management review meeting shall be held once a year . The meeting is allocated a maximum of 2:30 hours. The distribution is according to the following:

1 hour: presenting the review input.
30 minutes: questions and answers
1 hour: review output (it is recommended that this section is attended by the CEO, CISO, directors, and  heads of departments)

6.1.2 The Management review meeting to be chaired by CEO or CISO in case CEO is not available. In case CEO is not available, CISO must brief the CEO the finding and the output of the meeting with the CEO.

6.2 Agenda of MR:

6.2.1 Review Input: this part of the review shall include information on:

  1. Follow-up actions from previous management reviews.:This refers to all issues raised or resolved since the last review to make sure problems are being resolved properly. and to look for trends in the data. The action which was taken as result of the previous MRM must be reviewed. It must be verified that all the actions have been taken and also the effectiveness of the action taken must be verified. In case the the action was not completed or was found not to be effective, the root cause must identified and corrective action should be taken.
  2. Changes in external and internal issues that are relevant to the Information Security management system.
  3. Changes in needs and expectations of interested parties that are relevant to the information security management system;
  4. Status of non conformity and corrective actions. This refers to reporting of steps that have been taken to manage failures detected as well as steps to avoid the occurrence of any potential problems that are likely to rise.
  5. Process and result of performance monitoring and measurement. This refers to reporting whether XXX is reaching and/or maintaining performance targets.
  6. Results of audits. By reporting the results of audits carried during the previous period (internal and external). It should include the presentation of data analysis showing strengths and opportunities for improvement in the system.
  7. Information Security objectives: This refers to the Information Security objectives which was established during the previous MRM. The review must verify if the objectives were met and incase they were not met what was the root cause that it was not met and what corrective action was taken . Also the Information Security objective for the next year must be established based on the audit findings and the result of the performance monitoring and measurement.
  8. Feedback from Interested parties . Through analysis of reporting results of feedback from Interested parties that have been collected through various channels such as satisfaction surveys and compliments and complaints system. The reporting should look closely at both the negative and positive feedback.
  9. The result of the Event and Incident Reporting System and analysis.
  10. The effectiveness of actions taken to address risks as a result of risk assessment and the status of the risk treatment plan:
  11. Opportunities for continual improvement. This refers to proposing corrective and preventative actions to be taken based on the outcome of the review of the system carried out since the last MR in order to improve the quality of ISMS.

6.2.2 Review Output: This part of the review shall be allocated to discuss and decide on actions to be taken to improve the management system, services/ processes. and resource needed. The output shall include any decisions and actions related to:

  1. Improvement of the effectiveness of the Information management system and its processes. This refers to the fact that based on the information that has been discussed whether there are areas where worthwhile improvements can be made.
  2. Any need for change in Information Security Management System

6.3 Forms and records of the review:

The record of the review will be maintained by the IT department and a summary report of the meeting will be sent to the Management Representative.

7. RETAINED DOCUMENTED INFORMATION

7.1 Management Review record (ISMS F027)
7.2 Data analysis reports. (ISMS F028)
7.3 Management review agenda and minutes(ISMS F029)

Example of ISO 27001:2022 ISMS Awareness and Training Procedure

1.Purpose

The purpose of this procedure is to:
● Ensure protection of sensitive information regarding ISO 27001
● Provide system and instructions.
● Assign responsibilities for identifying training needs.
● Provide the required training for establishing awareness programs. And
● Maintaining training records.

2. Application

This procedure applies to all training and awareness programs.

3. Scope

All employees (classified, hourly, contractors, business partners)

4. Procedure

4.1 General

  • The objective of training program is to ensure that employees possess the required knowledge and skills for performing their jobs; and that they are familiar with relevant requirements of the information security systems pertaining to their job functions.
  • Awareness programs focus on understanding the importance of customer requirements, and the relevance of individual contributions towards meeting these requirements and achieving the security policy and objectives.
  • Employees are made aware of the types of device defects which may occur from the improper performance of their specific jobs.

4.2 Competence requirements, security and privacy awareness and training needs

  • Company-wide training and awareness programs are provided to all employees, irrespective of their function and position in the company. These programs include general orientation, rules and regulations, safety, and other such company-wide systems and issues. Compliance department with the SecOps unit and CISO are responsible for determining requirements and identifying training and awareness needs for company-wide programs.
  • Training and awareness programs will be perform when there is environmental or operational changes affect the security of electronic PHI (ePHI), credit card information or other sensitive data, for examples new or updated policies or procedures, new or upgraded software or hardware, new security technology, or new threats or vulnerabilities to ePHI and/or credit card information, and at least once a year. The training and awareness programs which perform at least once a year, will include:
    • Protection from Malicious Software – Any employee who has access to ePHI, credit card information or other sensitive data must be trained to identify the symptoms of malicious software, and the procedures for reporting and controlling such problems.
    • Log-In Monitoring – employees should be trained to recognize discrepancies in log-in procedures, and technical safeguards must be in place to detect suspicious log-in activity. Routine monitoring of account activity, such as detecting repeated incorrect password entries should be performed, and know how to recognize when their accounts may have been accessed without their knowledge.
    • Password Management – employees should be trained in creating, changing and safeguarding secure passwords. This guidance in particular must be periodically reviewed to ensure it remains effective as password requirements change over time.
  • Competence requirements and training needs for specific positions and jobs are defined in the Job Descriptions maintained by relevant departments, using Form Job Description.
  • Training needs for individual employees are determined on the basis of their education, experience and job performance, including periodical evaluations conducted by Human Resources

5. Company-wide training and awareness programs

5.1 General orientation training:

Human Resources provides employee orientation training to all new and existing employees. This training familiarizes employees with administrative rules, employee programs and benefits, etc.; and explains the product, product requirements, and the information security system:

  • Overview of the company’s information security system;
  • Discussion of security and privacy policy; and
  • Explanation of how individual employees can contribute to maintaining and improving the information security system.

Participation in the employee orientation training is recorded. These records are maintained by Human Resources

6.2 General orientation and information security system training:

  • The CISO is responsible for promoting constant awareness for information security among the users of information systems.
  • The Compliance Officer is responsible for issuing an awareness program at least once a year for information security which includes continuous awareness-training and updates. HR department is responsible for updating the Compliance department of incoming new employees (including their role, start date and employment emails). Compliance department is responsible for liaising with SecOps and the CISO to examine the most appropriate training courses as per certification/legal requirements and further based on the expert opinion of the CISO. Awareness for information security derives from constant exposure to security issues. The CISO is responsible for the allocation of training/marketing resources for security issues such as ePHI and/or credit card information including in the following issues:
    • Use of company-wide systems: Wide groups of employees are trained in the use of interdepartmental systems, such as part and material coding/numbering system, bar-code system, retrieval and creation of electronic (computer) documents and records, and so forth. Training is provided by the department that is responsible for the system. Training records are maintained by the department that provides training and monitored by the Compliance Officer to ensure enforcement.
    • Media Control: Training on media control covering removal and receipt of hardware/software including access control, accountability, data backup, data storage, mobile storage devices, and disposal of electronic data.
    • External training: Seminars, conferences, and other forms of external training. Requests for external training are evaluated and processed by Human Resources.
    • Self-study: The Company encourages personnel on all levels to read professional reports, magazines, and books. Requests for magazines and books are evaluated and processed by individual departments. Self-study is considered in formal recognition of skills as an alternative form of training. Where appropriate, self-study is recorded.
    • Report: Implementing an Incident response plan that helps employees identify potential incidents, and understand what steps to follow in the event of potential data breaches.
    • Document: Documentation of training is automated within the training monitoring tools which is supervised by the Compliance team

6.0 Training and Awareness Monitoring Tools

  • Learning Management System: The Company uses a Learning Management System (“LMS”) to complete the equired training courses online customized to the specific department and role they fulfill.
  • The courses are interactive and contain questions throughout that must be passed in order to receive the certificate for the specific course.
  • Emails are automatically sent to employees on their first day of employment from the LMS platform to set up their individual accounts and with a link to the required courses. Employees are required to complete critical security related courses within 1 week of the start of their employment.
  • Further retraining is required on a periodic basis (yearly and quarterly depending on the role within the company).
  • The LMS sends reminder emails 3 days before the completion deadline to employees who have not completed the required training.
  • An email is sent to the compliance department if the deadline has passed without completion of the required training. Further action will be taken if required

7.0 Departmental training

  • As part of their training, personnel are made aware of device defects which may occur from the improper performance of their specific jobs. Also, personnel who perform verification and validation activities are made aware of defects and errors that they may encounter.
  • On-the-job training, i.e. working under supervision of a more experienced employee, is provided to all personnel in any new or modified job affecting product quality. On the-job training is recorded, to include its scope, duration, and the name of the person who supervised the training.
  • Employees who have been performing their jobs or functions for at least six months prior to the initial implementation of this procedure may have their qualifications formally confirmed by their supervisors or departmental managers, without having to go through the initial training. This confirmation is documented in a written statement,
  • Including specific designation of the particular jobs and functions for which the employee is being confirmed. The confirmation record is equivalent to a training record, and is filed and maintained as such by Human Resources.
  • Employees who do not perform satisfactorily are provided with additional or repeated training.

8.0 Training effectiveness evaluation

The method used for evaluation of effectiveness for each training activity will be proportionate to the risk involved in the work for which the training is provided. The following methods and approaches are used for evaluating the effectiveness of training provided:

  • Follow-up evaluation of individual employees: Following competency or skill training, employees are evaluated by their supervisors or departmental managers. This evaluation assesses whether a particular training has achieved its objectives and if the employee is sufficiently competent and/or skilled to perform the new job function for which he or she was trained. Results of this evaluation are recorded and are kept together with the original training record.
  • Review of overall performance in areas related to particular training: When wider groups of employees are trained in safety, emergency procedures, or interdepartmental systems, this type of training is evaluated by comparing statistical performance data from before and after the training was provided. For example, the effectiveness of safety training is measured by tracking rates of work-related accidents.
  • Correlation of training with nonconformists and system failures: Training and competency are always considered when investigating causes of product and process nonconformities and failures of the information security system. When inadequate training is the cause, the investigation goes further to determine specifically which particular training is at fault. This training is then reviewed and improved, by changing its scope, format, or frequency, as appropriate.
  • Global evaluation of training by management review: Training and awareness programs and their effectiveness are evaluated by management reviews. This includes presentation and discussion of data correlating information security performance in particular areas with specific training and awareness programs. Operational Procedure, Management Review, defines this process.
  • LMS metrics: Employees must complete testing during the process of completing required courses within the LMS. Metrics are predefined to evaluate employee understanding of materials and to ensure an adequate level of comprehension based on the risk associated with each topic.