The healthcare industry faces many challenges, and maintaining regulatory compliance ranks high on the priority list for many leaders. Organizations often need help to meet these requirements due to the lack of knowledge, staff, skills, and costs.
In today’s article, we look at the vital steps every healthcare organization needs to take to become compliant.
Table of Contents
6 Steps Healthcare Organizations Needs to Take to Become Compliant
1. Get a Compliance Gap Analysis
Reid Johnston, Teal CIO and Cofounder, often hears healthcare leaders expressing apprehension regarding the security of their operations and how they need more visibility into their current security posture.
A compliance gap analysis gives your healthcare organization the insights needed to strengthen your compliance program – making it an essential resource. Reid explains that a gap analysis identifies the discrepancies between your current operation state and where you want to be.
"A gap analysis is vital for healthcare organizations for a number of reasons. Primarily it is beneficial to verify you have controls implemented, and that they are implemented in the way they are intended. Additionally, they gauge any unhandled risks within the scope of the assessment that may not have been identified in relation to your organization's compliance adherence, like hard drive encryption. Such gaps, while small to an organization’s overall security posture, can introduce a large amount of risk to the organization.”
Simple compliance missteps can have high costs. And when it comes to the government, if you don’t have proof, it’s assumed that all records are compromised. Here’s a real-life example.
Lifespan Health System Affiliated Covered Entity (Lifespan ACE), a nonprofit health system, experienced the theft of a hospital laptop that contained electronic protected health information (ePHI). The organization should have encrypted this data even after determining it was reasonable, but it did not. Due to this systemic noncompliance, Lifespan agreed to settle potential violations by paying $1.04 million and implementing a corrective action plan.
A gap analysis helps your organization avoid noncompliance, reputation damage, and costly legal action. An assessment can be conducted against common standards, such as:
- State Specific Information Security Requirements (Plastic Card Security Act, WA HB1149, etc.)
- Health Insurance Portability and Accountability Act (HIPAA)
- National Institute of Standards and Technology (NIST)
- Cybersecurity Maturity Model Certification (CMMC)
Compliance experts review your business’ technology, people, processes, policies, and procedures with the standards you fall under. When completed, they create a comprehensive plan that outlines your path to mitigate risk and achieve compliance.
2. Develop Compliance Policies and Procedures
Compliance policies and procedures should follow your gap analysis. Their focus will be on managing your business, employees, and customers within the scope of laws, industry regulations, and government legislation.
These policies provide safeguards against repercussions and uplift your healthcare organization by:
- Ensuring your organization remains in compliance with relevant laws and regulations.
- Educating your staff on best practices and how to address unethical or illegal behavior.
- Reducing the risk of your business being penalized, fined, sued, or shut down.
- Creating a healthy work environment, leading to increased productivity.
- Boosting your organization’s reputation in the public sphere.
Some organizations try to save money by using free online policy templates. While this can be a great place to start, Reid cautions that this approach requires attention to detail.
Your organization’s requirements and risk level may vary significantly from another. Because your organization has unique needs, it makes adaptation challenging. However, if you have compliance expertise available to you, it will be clear whether the policies correctly address applicable laws and regulations.
If you don’t have an internal compliance team, Reid recommends that you reach out to a managed compliance provider, like Teal, for assistance in creating these documents. They will ensure the policies meet your organization’s unique needs, are accurate, and protect you from repercussions.
Safeguard patient information and foster a strong reputation as a trusted healthcare provider with this self-assessment.
3. Create a Culture of Compliance
An area that many industries struggle with is employee training, and healthcare is among them. Reid explains the importance of creating a culture of compliance:
“Like other industries, human error is one of the biggest security and compliance threats your organization faces. Training your staff increases awareness and builds the success of your compliance program. Set the tone with clearly defined expectations as well as through regular training and education.”
Generally, training is conducted during onboarding and then each subsequent year of employment. However, you can adjust this to more frequent sessions if it makes sense for your organization.
Staff Training Should Include:
- Clinical staff
- Front office staff
- Administrators
- Executives
- Billers
- And more
Examples of Training Topics Include:
- How to handle protected health information (PHI).
- How to protect PHI from unauthorized access.
- How to identify and report security incidents.
- Proper documentation and record-keeping practices.
We understand that the healthcare industry faces staff shortages and a demanding schedule. But when you prioritize regular training, it will help safeguard your organization from noncompliance penalties.
Safeguard patient information and foster a strong reputation as a trusted healthcare provider with this self-assessment.
4. Implement Technical Safeguards
According to Verizon’s 2022 Data Breach Investigations report, medical data is taken in 22% of breaches – with the healthcare industry being the most common industry in these events. It’s vital that your organization employs the right technical solutions to protect ePHI (e.g., firewalls, encryption, and access controls). You must also follow best practices like installing software updates and timely patches to address vulnerabilities.
This industry is a growing target for run-of-the-mill hacking and ransomware attacks (learn about ransomware and HIPAA). This increase in cyberattacks makes specialized knowledge vital to your success. After all, your technology must be set up correctly to protect your organization and your patient’s information effectively.
The inherent complexities of information systems, cyber risks, and solutions force financially strained healthcare leaders to make challenging financial decisions. Many small/medium-sized healthcare organizations try to hire technical staff and struggle to find (or afford) the talent they need to manage their security and compliance. That’s why many turn to managed service providers (MSPs) for assistance in meeting their goals.
They provide the talent and robust solutions your organization needs and do it at a much lower cost than trying to do it all in-house. We recommend you check out this blog if you want to learn how to choose an MSP for your organization. Our experts created a resource you can use to make the vetting process less stressful.
5. Secure the Physical Environment
In addition to safeguarding technology, the healthcare industry must have physical safeguards to maintain compliance. Physical measures, policies, and procedures are vital to protecting ePHI.
You need to consider all physical access points to ePHI, including:
- Your healthcare organization’s office
- Physical storage centers
- Employees’ homes
Make sure you also consider portable media, such as laptops and USB drives. You need to be accountable for these items and thoroughly understand how to keep them secure using passwords, encryption, and physical control.
Key Components of Physical Safeguarding
Two critical components of a healthcare organization’s physical security are facility access controls and workstation use and device security.
Facility Access Controls
Facility access controls is the first standard under the physical safeguards section. Your goal is to effectively limit physical access to electronic systems through policies and procedures.
“A covered entity must limit physical access to its facilities while ensuring that authorized access is allowed.” – U.S. Department of Health & Human Services (HHS)
Covered entities must implement four specifications:
- Contingency Operations
- Facility Security Plan
- Access Control and Validation Procedures
- Maintenance Records
Workstation and Device Security
The workstation security standard must address how workstations are physically protected from unauthorized users (i.e., restricting physical access to a workstation in a secure room where only authorized staff work).
"A covered entity must implement policies and procedures to specify proper use of and access to workstations and electronic media. A covered entity also must have in place policies and procedures regarding the transfer, removal, disposal, and re-use of electronic media, to ensure appropriate protection of electronic protected health information (ePHI).”
The approach will vary by organization, and a risk analysis should be used during the decision-making process.
Our MSP does not manage the physical aspects of healthcare environments. However, we can assist organizations with creating policies and procedures to protect ePHI.
Other MSPs can assist your organization as well. When choosing a provider, selecting one with in-depth knowledge of your industry is essential. This expertise will ensure you are meeting your complex compliance requirements.
6. Conduct Regular Audits
Internal and external audits outline your path to compliance. They identify weaknesses and inform your organization of the success of your program. In combination with the right plan, audits help reduce security risks and help your organization avoid costly legal action or federal fines for noncompliance.
Healthcare organizations should conduct internal audits at least once a year. It’s important to understand the individual requirements of each one your business must adhere to because each compliance standard has unique rules for external audits.
To properly prepare for audits, ensure your organization has access to a robust internal compliance team or a managed service provider with experience in the healthcare industry.
7. Maintain Business Associate Agreements
You likely already know that, according to the Final Omnibus Rule, entering into Business Associate Agreements is vital before ePHI is disclosed to a Business Associate. Less commonly known, though, is that Business Associates must also enter into a Business Associate Agreement before disclosing ePHI with a subcontractor.
Ensure it is explicitly stated in the contract that your Business Associates must use appropriate safeguards to prevent abuse or disclosure of protected health information.
Closing the GAP: Protect Your Reputation and Bottom Line
Regulatory compliance requirements serve to protect your organization. Every healthcare organization – from hospitals to private practice – is obligated to safeguard their patients’ personal information. Those who take proactive steps will avoid legal fees, build trust, and provide better patient care.
Do you need help to meet compliance requirements? If you said yes, getting a gap analysis is your first step in closing the compliance gap. Our compliance analysis is cost-effective and will set your organization up for success.
Our experts talk to multiple levels of your organization during your gap analysis – executives, middle managers, and line workers,” said Reid. “This allows us to get a holistic view of the environment, determine where data is stored, and see how it is handled.”
Get Strategic Managed IT Services
Teal’s highly certified team regularly assists healthcare organizations in meeting compliance goals. They possess a comprehensive understanding of your industry’s unique challenges and offer the best routes you can take to solve them.
Our professionals also differentiate themselves from other MSPs by their deep commitment to delivering obsessive service to our partners. Discover how we fulfill our promises to clients with Net Promoter Surveys and our unique quality assurance processes.
You provide the best healthcare possible for your patients. Now, elevate your organization’s reputation and security with expert IT strategies.
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