hipaa-as-3 High priority Administrative Safeguards / Workforce Security

Implement procedures to ensure workforce members have appropriate access to ePHI and prevent unauthorized access

Not every workforce member should have access to all ePHI. Organizations must implement procedures to authorize and supervise workforce access, determine whether access is appropriate before granting it, and terminate access when a workforce member leaves or changes roles. Insider threats, both malicious and accidental, are a leading cause of healthcare data breaches. Strong workforce security controls limit damage by ensuring people only access what they need for their job.

6h estimated effort

hipaa access-control workforce offboarding

Implementation steps

1

Establish authorization and supervision procedures

Define which workforce roles require access to ePHI and what level of access is appropriate for each role. Implement a formal process for authorizing access, requiring manager and security officer approval before access is granted. Periodically review access authorizations to verify they remain appropriate.

okta azure-ad confluence
2

Implement workforce clearance procedures

Establish procedures to determine that workforce members' access to ePHI is appropriate. This may include background checks for roles with high access to sensitive ePHI. Document the clearance criteria and decisions. Clearance requirements should scale with the sensitivity and volume of ePHI the role can access.

confluence excel
3

Define and execute termination procedures

Establish procedures to terminate ePHI access when a workforce member's employment ends or their role changes. Access should be removed promptly, ideally on or before the last day of employment. Include return of physical access devices (badges, keys) and revocation of logical access (accounts, VPN, remote access). Test the process periodically.

okta azure-ad servicenow jira