6 Steps To Ensure HIPAA Compliance Management

Brian Williams, MHA, MBA
healthcare professional and administrator walking in crowded hospital

You wouldn’t want to have your personal information fall into the hands of the wrong individual. Neither do the patients who come to a healthcare facility for treatment. Their Protected Health Information (PHI) includes their medical records and other private, identifying information. To ensure the safety of PHI, healthcare organizations have a responsibility to keep it safeguarded through HIPAA compliance management and by following the Health Insurance Portability and Accountability Act (HIPAA).

What Is HIPAA Compliance?

HIPAA rules are strict regarding the handling of electronic PHI by covered entities or business associates. Ensuring that sensitive data is protected is of the utmost importance! The regulations set forth by HIPAA are intended to ensure data security, and to mitigate the risk of theft and other malicious activities.

Any organization that fails to adhere to HIPAA rules renders itself noncompliant and is subject to serious penalties. Covered entities and business associates must devote considerable effort and resources to ensuring that principles of confidentiality, integrity, and availability of PHI are protected throughout all stages of data handling.

Achieving and maintaining HIPAA compliance management takes ongoing effort and dedication. Here are six tips to help make sure your organization keeps PHI protection top-of-mind.

How Do You Maintain HIPAA Compliance?

1. Document Everything

By staying up-to-date with compliance regulations, healthcare organizations can safeguard patients’ PHI and maintain their trust. That means developing privacy and security policies and procedures, and documenting them thoroughly to avoid HIPAA violations.

Another important step in this process is ensuring that a written agreement — a Business Associate Agreement (BAA) — is in place with each organization or vendor who transmits or receives PHI. Choose a compliance platform that makes it easy to complete this document online and even store it with other contracts to receive automatic reminders when BAAs lapse, allowing for proactive measures.

Watch this video to learn more about digitizing all your documents and policies.

2. Protect Against Third-Party Risks

As healthcare relies more and more on technology, third-party software companies are increasingly critical in managing PHI. However, these third parties can also be a source of increased risk when it comes to data breaches.

According to MagMutual, 51% of organizations across all industries have suffered a data breach due to the actions of a third party.

Third parties should be held to the same high standard as employees in terms of security practices, and there are several best practices that can help reduce potential risks.

Periodic security audits can help ensure that third parties adhere to the appropriate standards. To aid in the event of a breach, healthcare companies should also maintain access to contracts and contact information for third-party vendors. Finally, IT should ensure that third-parties have access only to the information and systems necessary to complete their work.

With these practices in place, healthcare professionals can minimize the risk of third-party breaches, while optimizing the security and management of PHI.

3. Build Internal Relationships

HIPAA compliance is a complex and multi-faceted undertaking that requires collaboration from different departments within an organization. One of the most critical areas in this framework is IT. Access management, proper use of workstations and electronic media, integrity controls, and transmission security all fall under IT’s purview. IT’s role is crucial in ensuring that the organization is compliant with HIPAA regulations.

It can’t be overstated how crucial it is for a compliance officer to work closely with IT and legal teams to prepare for a HIPAA breach — or any other incident. Having processes and policies in place before can help to ensure efficient communication and collaboration during any situation. Storing your documentation in a cloud-based compliance platform will ensure it is accessible anytime, anywhere.

4. Appoint Privacy and Security Officers

Keeping tabs on the progress your staff makes in training is important for HIPAA compliance management, yet it can be challenging to monitor everyone at the same time. Centralizing compliance training records and automating training reminders is the best way to keep everyone on staff up-to-speed with HIPAA standards. This is also critical for appointing and training Privacy and Security Officers, who need to be stewards for accountability.

Centralizing employee training and certifications makes it easy to gauge compliance across an organization — whether your operations span a few floors or across multiple campuses. From the moment they’re onboarded to annual trainings to ensure compliance, all employee training needs to be tracked. More importantly, there needs to be a Privacy or Security Officer behind it, to keep everyone accountable.

For organizations that don’t have the scope or budget to delegate this task to a full-time professional, digital software can bridge many of the gaps. Automation goes a long way toward ensuring everyone is properly educated, trained, and accountable.

5. Regularly Conduct a Security Risk Assessment

By regularly conducting a security risk assessment, healthcare organizations can proactively identify potential areas of vulnerability. Even a simple HIPAA risk assessment checklist can become a powerful tool for healthcare organizations. A checklist offers a straightforward approach to assessing how your organization handles patients’ most sensitive information, and if processes and procedures are in compliance with state and federal regulations.

6. Provide Frequent HIPAA Training

HIPAA training is an essential requirement for all healthcare employees. In fact, it’s mandatory to complete the training annually — and recommended even more often. To make it easy for employees to stay on top of their training, many organizations offer it online. This way, workers can complete the necessary courses at their own pace.

It’s important to choose a learning management system (LMS) that includes learning checks and verification of completion to ensure that all requirements are met. Additionally, full HIPAA courses should be offered annually, and microlearning courses should be made available periodically throughout the year. Look for an LMS that provides healthcare-specific courses with a variety of HIPAA training material to keep employees engaged.

How Do You Manage HIPAA Compliance?

Management of HIPAA compliance requires the participation of everyone in an organization, from front desk staff and providers all the way to leadership. Tracking and ensuring everyone’s accountability can be difficult, especially if your practice consists of multiple locations. So, while you now have six ways of maintaining HIPAA compliance, how do you go about managing all of these elements?

One thing is for sure: documenting employee training, incident reports, policy acknowledgments, and procedural updates by paper is outdated, inefficient, and exposes an organization to noncompliance. Not only do papers get lost, but housing them in filing cabinets or binders limits organizational transparency, making it incredibly difficult for a compliance officer or surveyor to easily access reports and status updates.

The wisest way to tackle HIPAA compliance management is by leveraging technology to:

  • Increase transparency by digitally housing policies for easy retrieval by anyone
  • Enforce individual accountability through automated acknowledgement reminders
  • Educate staff on HIPAA policy with flexible e-learning
  • Enable real-time reporting to verify that all staff are on the same page and held to the same standards

Utilizing a trusted compliance software can propel organizations towards a more streamlined, efficient, and compliant approach to protecting patient information.

HIPAA Compliance Management Software

Keeping patient information secure is of the utmost importance for healthcare organizations. With the ever-changing landscape of regulations and policies, it can be challenging to keep up with the latest requirements. MedTrainer can help. Our all-in-one compliance platform streamlines education, credentialing, and compliance documentation to keep you organized and ready for your next challenge.


See how MedTrainer can streamline your compliance.