HIPAA Compliance is a term that is often thrown around the healthcare industry; however, I commonly ask myself – is the meaning of HIPAA Compliance the same throughout the industry? The answer is NO! Walking into a healthcare organization in the last month, the HIPAA Privacy Officer was excited to tell me that they are fully HIPAA compliant and don’t have any on-going concerns with meeting the regulations. A quick review of the documentation requirements and auditing practices indicated that there were many missing holes in their HIPAA Compliance Program. As I spoke with the HIPAA Privacy Officer, she provided me with the tool she used to get to their current state with HIPAA. Needless to say, the tools were missing core components of documentation requirements and didn’t have specific essentials for on-going maintenance for compliance. This left the organization at risk for a HIPAA data breach or unauthorized use or disclosure of health information!
Trying to achieve a satisfactory level of HIPAA compliance at an organization can be a frustrating and daunting task. Sitting down looking at the rule can be overwhelming. Digging through the pages of information in a HIPAA manual or diving into the Federal Register can be impossible with all the other tasks assigned within a job. In addition, it is easy to want to sit down and solve the HIPAA compliance issue you have in one day or one week; however, this often leads to failure and inability to create a program that protects your patient information.
We don’t wake up one morning, decide to run a marathon and go out and accomplish the overwhelming 26.2 miles (well most of us). Normally if you are going to run a marathon, you find a training program that lasts 16-18 weeks, create a plan for cross training activities within your training program, and ask for support and help along the way. That concept and mindset can transferred to HIPAA compliance as well!
One of the most effective ways to properly implement a solid HIPAA program is creating an action plan for compliance and assigning small regular tasks to get through entire HIPAA regulation. It is very important that HIPAA is an on-going process within the organization. It is not just a ‘one and done’ type of regulation due to the nature of work that we do in healthcare and the vast changes within our technologies used.
To help with HIPAA Compliance – here are 5 Essential Steps that must be taken to achieve a solid HIPAA Compliance Program.
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- Conduct a Risk Assessment/Analysis – if you haven’t conducted a risk analysis recently, it might be a great idea to conduct one again soon. Make sure to have a risk analysis report that provides information on how the audit was conducted, what systems were evaluated and what the identified risks were. Remember – don’t stop there. You must create a risk management plan and mitigate and/or address all the risks identified.
- Create, Review and/or Update all HIPAA policies and procedures – policies and procedures create the foundation for success with HIPAA compliance. Conduct a gap analysis on your policies and procedures. Look for policies that you may be missing or policies that don’t meet minimum compliance. Then ensure that your organization is following the policies you have created. Use the HIPAA audit protocol as a guide for the policies and procedures. It sets up expectations of what should be written in policies and procedures.
- Provide Workforce HIPAA Education – educating your entire workforce becomes an essential step in HIPAA compliance. Your workforce should know and understand what HIPAA is and the processes and procedures that are established within your organization, including understanding where the HIPAA policies and procedures are stored and maintained.
- Conduct regular HIPAA Audits – HIPAA established requirements for the regular audits to show HIPAA compliance with the regulation as well as understanding who is accessing what protected health information for what purpose. A strong HIPAA audit program can help reduce the risk of internal threats and external inappropriate access to systems. Additionally, it allows an organization to understand the areas where they might be out of compliance and make the appropriate actions to meet compliance.
- Use Security Technologies – HIPAA doesn’t mandate the use of any specific technology; however, the use of technology can help support HIPAA compliance within an organization. An organization should working with the information technology department or information technology vendor to determine where security technologies can be used in assisting with HIPAA compliance. Some technologies may include encryption, intrusion detection software, or audit logging software.
Again, take the mindset of working a little one these tasks each week and eventually you will get there. Anyone can build a solid HIPAA compliance program that has all the necessary components of the regulations! Don’t wait – act now!