You facility is responsible for maintaining its HIPAA Compliance all year long. And your staff are the ones who ensure that compliance is achieved through their daily actions. But if you don’t weave your HIPAA compliance policies and procedures into the garment of your facility’s culture, it can hardly be expected that your staff will never make a misstep, putting your patients and your facility at risk.
A Security Awareness Plan (SAP) is the tool your company uses to make sure your staff is performing their daily due diligence to meet HIPAA compliance regulations throughout the year.
A healthcare facility goes through a series of steps when creating an SAP. It starts with developing your facility’s compliance policies and procedures. You then assign the responsibilities for managing those policies and procedures to appropriate individuals within your team, train them to handle those responsibilities, and conduct regular tests to make sure due diligence is always upheld. Any errors that are found are corrected, the policies and procedures are updated to eradicate the identified gaps, and the process repeats.
A well designed plan creates awareness within your facility about the dangers it faces if it isn’t compliant – not so that your staff are afraid of the penalties, but so that they are proactive to avoid them.
Below are five elements that we consider critical to a strong Security Awareness Plan:
- Do you even have a security awareness plan?
Have you defined a plan specific to maintaining and updating your HIPAA compliance throughout the year? This is step number one.
- Have you conducted initial and ongoing training?
Every employee hired should receive initial training on how to ensure HIPAA compliance, and their training should be continued throughout the year. Additionally, if there is a breach, you have to retrain where necessary so the breach doesn’t occur again.
- Are you communicating ongoing awareness around HIPAA Compliance?
This includes communicating with your staff who your security officers are, what your policies and procedures are so they know and understand them, updating your staff on any changes to the policies and procedures when they occur, and updating them on recent breaches.
This element of an SAP is so important because this is what creates the culture of security awareness within your facility. If you don’t talk about it regularly, your staff will forget about it and violations become that much more likely to occur. Beyond the penalties your facility will face, a violation will also hurt your facility’s reputation within the community.
- Have you established standard operating procedures for achieving active HIPAA compliance?
Your security officer is at personal risk if there is a violation and can be personally held accountable for someone else’s mistake within your organization. That’s why it is critical to have routine procedures set up to make staying compliant a habitual behavior with all of your staff.
- Is your security officer being held accountable?
Accountability is key to making sure your SAP is an active process all year long. Scheduling accountability meetings with our clients is how we work to help the security officer develop this ongoing plan and enforce it. We’ve seen that without these meetings, it can be difficult for the security officer to find the time to maintain their SAP.
An ongoing Security Awareness Plan is the most important thing your facility can do to maintain HIPAA compliance. It doesn’t do you any good to address HIPAA compliance once a year. Compliance is a daily activity, and an ongoing Security Awareness Plan is instrumental in your success.