hipaa-as-1 Critical priority Administrative Safeguards / Security Management Process

Implement a security management process to prevent, detect, contain, and correct security violations

The foundation of HIPAA Security Rule compliance is a formal security management process. Organizations must conduct a thorough risk analysis to identify vulnerabilities that could expose ePHI, implement a risk management program to reduce those risks to a reasonable level, apply sanctions against workforce members who violate policies, and regularly review information system activity such as audit logs and access reports. Without this foundation, all other safeguards lack the direction and oversight needed to be effective.

16h estimated effort

risk-management risk-analysis hipaa security-management

Implementation steps

1

Conduct a thorough risk analysis

Perform a documented risk analysis that identifies all ePHI your organization creates, receives, maintains, or transmits; all threats and vulnerabilities that could affect the confidentiality, integrity, or availability of that ePHI; the current controls in place; and the likelihood and impact of each threat exploiting each vulnerability. This is the required first step and must be repeated whenever significant changes occur.

excel confluence nist-risk-assessment
2

Implement a risk management program

Based on the risk analysis, implement security measures that reduce identified risks to a reasonable and appropriate level. Document your risk management decisions, including why specific controls were selected or accepted. Prioritize high-likelihood, high-impact risks. Review and update the risk management program on an ongoing basis as your environment and threat landscape changes.

excel confluence jira
3

Establish and apply a sanction policy

Create a written sanction policy that specifies the consequences for workforce members who fail to comply with security policies and procedures. Sanctions should be proportional to the severity of the violation. Document sanctions that are applied. The existence of a sanction policy, combined with workforce training on it, deters non-compliance.

confluence excel
4

Implement information system activity review

Establish procedures to regularly review records of information system activity such as audit logs, access reports, and security incident tracking reports. Frequency should be based on risk: systems with higher access to ePHI should be reviewed more often. Assign responsibility for reviews and document findings.

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