How do we…
How do we decide which systems belong in the review?
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The short answer
- Recommendation
- Put a system in the review if any one of four tests is true: it supports a critical service; it holds personal, financial or sensitive business data; it grants administrator access to other in-scope systems; or it moves money, changes key records or approves transactions. Then give it a named owner and a tested extract.
- Reasoning
- One test is enough, so a shared finance drive is as much in scope as the finance application. Every account on an in-scope system is reviewed, including supplier and service accounts. Without an owner nobody can decide the permissions, and without a complete extract the system cannot be reviewed at all, so either gap is a finding in itself. Where you do not know the answer to a test, treat the system as in scope until someone who knows has looked.
- Considerations
- The four tests are the pack's, and your organisation may add systems to them. A critical service includes a critical or important function under DORA and any system holding cardholder data.
- Leaving out a system that meets a test is a formal exception, recorded in your exception register.
- Physical access to buildings, and customers' own accounts without administrative rights, are outside this review.
- A small organisation can start with the directory administrator groups, the finance system and the system customers use, and add the rest at later campaigns.
The decision, step by step
Select any step for the reasoning behind it and where the pack covers it.
- Start
- Step
- Decision
- Outcome
Keyboard: Tab to a step, arrow keys move along the flow, Enter pins its explanation, + and − zoom, 0 fits the diagram, Esc closes. The text version below has the same content.
Where a step quotes a number, it is the default in the CISO Times pack. Your own standard may set a different one.
Read as text
The same flow written out: each step, its reasoning and where the pack covers it. 12 steps.
Start
Deciding whether a system belongs in the access review
Take each candidate system in turn. Start with the systems behind your critical services and every system that gives administrator access. A small organisation can begin with the directory administrator groups, the finance system and the system customers use, and add the others at the next campaign.
In the pack
- P07-A04 Access Review Scope & System InventoryInstructions
- P07-A02 Access Review MethodologyAdapting this template
Decision
Does it support a critical service?
Include any system supporting a critical or important function under DORA, and any system that stores, processes or transmits cardholder data. If you do not yet know which services are critical, answer yes for now.
- Yes, or not known: Add it to the inventory with its scope and frequency
- No: Does it hold personal, financial or sensitive business data?
In the pack
- P07-A02 Access Review MethodologySystems
Decision
Does it hold personal, financial or sensitive business data?
Commercially sensitive data counts as well as personal and financial data. A shared finance drive is as much in scope as the finance application. If you do not know what it holds, answer yes until someone who does has looked.
- Yes, or not known: Add it to the inventory with its scope and frequency
- No: Does it grant administrator access to other in-scope systems?
In the pack
- P07-A02 Access Review MethodologySystems
Decision
Does it grant administrator access to other in-scope systems?
Directories, cloud consoles, firewalls, databases and backup systems all qualify. Administrator access to the directory reaches every other system, which is why the pack reviews it most often.
- Yes, or not known: Add it to the inventory with its scope and frequency
- No: Does it move money, change key records or approve transactions?
In the pack
- P07-A02 Access Review MethodologySystems
- P07-A02 Access Review MethodologyExample 2 — SYS-03, the directory administrator groups: privileged access
Decision
Does it move money, change key records or approve transactions?
Key records are supplier and customer records, such as bank details. These systems carry the fraud risk that segregation-of-duties checks in the review are meant to catch. Add any other test your organisation needs here.
- Yes, or not known: Add it to the inventory with its scope and frequency
- No: Leave it out, and test it again when the system changes
In the pack
- P07-A02 Access Review MethodologySystems
- P07-A02 Access Review MethodologySegregation-of-duties conflicts
Outcome
Leave it out, and test it again when the system changes
It meets none of the tests. Physical access to buildings, and customers' own accounts without administrative rights, are outside this review anyway. Run the tests again when the system changes, and whenever the review method itself is reviewed.
In the pack
- P07-A02 Access Review MethodologyNot in scope
- P07-A02 Access Review MethodologyReview
Step
Add it to the inventory with its scope and frequency
Give it a system ID that never changes, and the scope that sets its frequency. A system with both administrator and ordinary access needs two rows, or one row reviewed at the shorter interval. Leaving out a system that meets a test is a formal exception in your exception register.
In the pack
- P07-A04 Access Review Scope & System InventoryInventory
- P07-A04 Access Review Scope & System InventoryInstructions
Step
Include every account, not only staff accounts
Personal, privileged, generic or shared, service and third-party accounts are all reviewed. A supplier's support staff are third-party accounts. Service accounts are reviewed with the system they run on. Note which kinds the system has, so the right reviewers are assigned.
In the pack
- P07-A02 Access Review MethodologyAccounts
Decision
Does it have a named system owner?
The system owner is the manager accountable for the system. They decide what its roles allow and answer for its privileged and generic accounts. Without one, nobody can decide the permissions.
- Yes: Has a test extract listed every account with all four fields?
- No, or not known: Raise the gap as a finding and fix it before the campaign
In the pack
- P07-A02 Access Review MethodologySystems (rule AR-01)
- P07-A02 Access Review MethodologyDefinitions
Decision
Has a test extract listed every account with all four fields?
The four fields are name, role, permissions and last sign-in. The count must match the system's own count, and local accounts outside the directory must be included. Test it before the campaign's extract date. If it has not been tested, answer no.
- Yes: In scope, and ready for its next campaign
- No, or not known: Raise the gap as a finding and fix it before the campaign
In the pack
- P07-A04 Access Review Scope & System InventoryExtract Readiness
- P07-A02 Access Review MethodologyInputs (rule AR-03)
- P07-A02 Access Review MethodologyLimitations
Outcome
Raise the gap as a finding and fix it before the campaign
A system without an owner, or without a way to extract who has access, cannot be reviewed. That is itself a finding, reported with the campaign. If the system cannot give last sign-in, find where it comes from, usually the directory, or have the system owner name every unused account.
In the pack
- P07-A02 Access Review MethodologySystems
- P07-A02 Access Review MethodologyInputs
Outcome
In scope, and ready for its next campaign
The system is listed with its owner, scope, account kinds and a tested extract. Plan the next campaign from the earliest review due date across your inventory.
In the pack
- P07-A04 Access Review Scope & System InventorySummary
Practical checklist
- Start with the systems behind your critical services and every system that gives administrator access.
- Test each system against the four scope tests, answering yes where you do not know.
- Add each in-scope system to the inventory with a system ID that never changes, its scope and its frequency.
- Note which kinds of account it has: personal, privileged, generic or shared, service and third-party.
- Name the system owner: the manager accountable for the system.
- Test an extract before the campaign: name, role, permissions and last sign-in, with the count matching the system's own.
- Raise a missing owner or extract as a finding, and fix it before the campaign.
- Run the tests again when a system changes and whenever the review method is reviewed.
Evidence to have ready
- The inventory of in-scope systems, with each one's owner, scope, account kinds and extract method.
- The test extract for each system, with its date and the count reconciled to the system's own.
- Each finding for a system without an owner or a usable extract, and the exception for any system left out.
Assumptions
- You are building or checking a list of systems for access review, even an incomplete one.
- The scope tests are those in the CISO Times access review pack. Your own method may add systems to them.
Not covered here
- How often each system is reviewed, and by whom. That is “How often do we review access, and who does the reviewing?”.
- Systems run for you by a supplier. That is “How do we review access to a system a supplier runs for us?”.
- Deciding to leave out a system that meets a test. That needs a formal exception (“When does a deviation from policy need a formal exception?”).