Navigating the complex landscape of healthcare compliance can be daunting, even for seasoned IT professionals. The HITRUST certification, governed by the Health Information Trust Alliance, is a gold standard for ensuring compliance and the security of sensitive healthcare data. With cyber threats continually evolving, healthcare organizations face high scrutiny to safeguard patient information.
The HITRUST CSF (Common Security Framework) has become the most adopted security framework in the healthcare industry in the United States. This certification combines various compliance requirements, including HIPAA, NIST, and ISO, into a single overarching framework, providing a streamlined pathway to achieving multiple compliance objectives. To arm you with the knowledge you need, here are expert suggestions for each phase of preparing for and undergoing a HITRUST assessment:
Understand the Scope and Prepare the Team
A HITRUST assessment is not a one-size-fits-all approach; it varies depending on the size of your organization, the types of data you handle, and the systems and applications you employ. An initial scoping exercise is crucial to identify the organizational units, business processes, and technologies that will be part of the assessment. At this stage, forming a dedicated team is imperative. This team should consist of members from IT, Compliance, Legal, Operations, and any other departments that manage sensitive data. This cross-functional approach ensures that all stakeholders are involved in the certification process, providing unique perspectives that can be invaluable during the assessment. Involving executive management offers a strategic advantage and ensures adequate resources are allocated for a successful assessment.
Conduct a Gap Analysis
Before embarking on an assessment, it's crucial to understand where your organization currently stands in terms of compliance. Conduct a gap analysis to identify areas where you are already compliant and areas that need work. Utilize HITRUST's MyCSF tool, leverage a HITRUST Readiness Licensee like Steel Patriot Partners, or consult a certified HITRUST external assessor for this purpose. With visibility into your organization's compliance maturity, completing a successful assessment or certification will be possible. HITRUST requires a passing score of 3+ in every domain or 3 with Correction Action Plans (CAPs).
Prioritize and Remediate
After completing a thorough gap analysis, prioritize the areas that need improvement based on their level of risk to the organization. Create a remediation plan detailing the corrective actions required, the responsible teams, and a realistic timeline. Adopting a phased approach to remediation, focusing first on areas with a higher risk profile to address the most significant assessment gaps.
Simulate an Audit
A simulated audit or 'mock assessment' is an invaluable step to prepare for the actual assessment. Completing this will help your team familiarize themselves with the questions that auditors may ask and how to provide adequate answers. Cybersecurity advisory firms suggest that this practice can help uncover areas of weakness that may not have been apparent during the initial gap analysis.
Maintain Documentation and Conduct Regular Reviews
Thorough documentation is not just a requirement but a critical factor that HITRUST auditors scrutinize. When documenting, remember to include all policies, procedures, risk assessments, and even correspondence showing that you have addressed issues that arose during the remediation process. Given that the HITRUST framework evolves to align with new regulatory requirements and emerging security risks, maintaining up-to-date documentation is imperative for passing the initial assessment, recertification, and interim assessments. It's not a "one-and-done" process; HITRUST requires organizations to continually monitor their security controls and adjust to maintain compliance. This ongoing commitment to cybersecurity hygiene isn't just about keeping auditors at bay; it's about safeguarding the reputation and trustworthiness of your organization in a competitive healthcare market where patients and partners alike expect the highest standards in data protection.
How does Steel Patriot Partners fit into HITRUST?
As a HITRUST external assessor, Steel Patriot Partners assists organizations in understanding the full scope of their compliance needs, assembling a multifaceted team, and maintaining meticulous records so that organizations can successfully navigate the complexities of a HITRUST assessment, no matter the level they are trying to achieve. Having an external partner like Steel Patriot Partners and achieving any HITRUST certification helps healthcare organizations meet regulatory requirements and fortify their security infrastructure, reducing risks.
About the Author
Amy Ford, COO and HITRUST Practice Lead, Steel Patriot Partners
Amy has devoted her career to understanding operations comprehensively, from managing IT teams that provide 24/7 customer support to overseeing Human Resources and assessing business risks. Her enthusiasm lies in resolving problems and providing effective solutions that leverage her passion for information security compliance. Amy co-founded Steel Patriot Partners, which delivers solutions that simplify implementing governance, compliance, and cybersecurity. Drawing on her decades of experience in operations, compliance, human resources, and business management, Amy oversees compliance and the HITRUST practice at Steel Patriot Partners.