An essential guide to the HIPAA Minimum Necessary Standard (2023)

These days, cybercrime is rampant. It’s no longer a matter of “if” you’re going to suffer an attack but “when” it will happen. All companies want to be ready for any crisis. And this is where a business continuity plan comes into play.

But what is a business continuity plan exactly? Why is it important? What should one include? Today, we’re exploring all these questions in-depth.

What is a business continuity plan?

A business continuity plan (BCP) is a document that sets guidelines for how an organization will continue its operations in the event of a disruption, whether it’s a fire, flood, other natural disaster or a cybersecurity incident. A BCP aims to help organizations resume operations without significant downtime.

Unfortunately, according to a 2020 Mercer survey, 51% of businesses across the globe don’t have a business continuity plan in place.

What’s the difference between business continuity and disaster recovery plans?

We often confuse the terms business continuity plan and disaster recovery plan. The two overlap and often work together, but the disaster recovery plan focuses on containing, examining, and restoring operations after a cyber incident. On the other hand, BCP is a broader concept that considers the whole organization. A business continuity plan helps organizations stay prepared for dealing with a potential crisis and usually encompasses a disaster recovery plan.

Importance of business continuity planning

The number of news headlines announcing data breaches has numbed us to the fact that cybercrime is very real and frequent and poses an existential risk to companies of all sizes and industries.

Consider that in 2021, approximately 37% of global organizations fell victim to a ransomware attack. Then consider that business interruption and restoration costs account for 50% of cyberattack-related losses. Finally, take into account that most cyberattacks are financially motivated and the global cost of cybercrime topped $6 trillion last year. The picture is quite clear — cybercrime is a lucrative venture for bad actors and potentially disastrous for those on the receiving end.

To thrive in these unpredictable times, organizations go beyond conventional security measures. Many companies develop a business continuity plan parallel to secure infrastructure and consider the plan a critical part of the security ecosystem. The Purpose of a business continuity plan is to significantly reduce the downtime in an emergency and, in turn, reduce the potential reputational damage and — of course — revenue losses.

Business continuity plan template

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Business Continuity Plan Example

[Company Name]

[Date]

I. Introduction

  • Purpose of the Plan

  • Scope of the Plan

  • Budget

  • Timeline

The initial stage of developing a business continuity plan starts with a statement of the plan’s purpose, which explains the main objective of the plan, such as ensuring the organization’s ability to continue its operations during and after a disruptive event.

The Scope of the Plan outlines the areas or functions that the plan will cover, including business processes, personnel, equipment, and technology.

The Budget specifies the estimated financial resources required to implement and maintain the BCP. It includes costs related to technology, personnel, equipment, training, and other necessary expenses.

The Timeline provides a detailed schedule for developing, implementing, testing, and updating the BCP.

II. Risk Assessment

  • Identification of Risks

  • Prioritization of Risks

  • Mitigation Strategies

The Risk Assessment section of a Business Continuity Plan (BCP) is an essential part of the plan that identifies potential risks that could disrupt an organization’s critical functions.

The Identification of Risks involves identifying potential threats to the organization, such cybersecurity breaches, supply chain disruptions, power outages, and other potential risks. This step is critical to understand the risks and their potential impact on the organization.

Once the risks have been identified, the Prioritization of Risks follows, which helps determine which risks require the most attention and resources.

The final step in the Risk Assessment section is developing Mitigation Strategies to minimize the impact of identified risks. Mitigation strategies may include preventative measures, such as system redundancies, data backups, cybersecurity measures, as well as response and recovery measures, such as emergency protocols and employee training.

III. Emergency Response

  • Emergency Response Team

  • Communication Plan

  • Emergency Procedures

This section of the plan focuses on immediate actions that should be taken to ensure the safety and well-being of employees and minimize the impact of the event on the organization’s operations.

The Emergency Response Team is responsible for managing the response to an emergency or disaster situation. This team should be composed of individuals who are trained in emergency response procedures and can act quickly and decisively during an emergency. The team should also include a designated leader who is responsible for coordinating the emergency response efforts.

The Communication Plan outlines how information will be disseminated during an emergency situation. It includes contact information for employees, stakeholders, and emergency response personnel, as well as protocols for communicating with these individuals.

The Emergency Procedures detail the steps that should be taken during an emergency or disaster situation. The emergency procedures should be developed based on the potential risks identified in the Risk Assessment section and should be tested regularly to ensure that they are effective.

IV. Business Impact Analysis

The Business Impact Analysis (BIA) section of a Business Continuity Plan (BCP) is a critical step in identifying the potential impact of a disruption to an organization’s critical operations.

The Business Impact Analysis is typically conducted by a team of individuals who understand the organization’s critical functions and can assess the potential impact of a disruption to those functions. The team may include representatives from various departments, including finance, operations, IT, and human resources.

V. Recovery and Restoration

  • Procedures for recovery and restoration of critical processes

  • Prioritization of recovery efforts

  • Establishment of recovery time objectives

The Recovery and Restoration section of a Business Continuity Plan (BCP) outlines the procedures for recovering and restoring critical processes and functions following a disruption.

The Procedures for recovery and restoration of critical processes describe the steps required to restore critical processes and functions following a disruption. This may include steps such as relocating to alternate facilities, restoring data and systems, and re-establishing key business relationships.

The Prioritization section of the plan identifies the order in which critical processes will be restored, based on their importance to the organization’s operations and overall mission.

Recovery time objectives (RTOs) define the maximum amount of time that critical processes and functions can be unavailable following a disruption. Establishing RTOs ensures that recovery efforts are focused on restoring critical functions within a specific timeframe.

VI. Plan Activation

  • Plan Activation Procedures

The Plan Activation section is critical in ensuring that an organization can quickly and effectively activate the plan and respond to a potential emergency.

The Plan Activation Procedures describe the steps required to activate the BCP in response to a disruption. The procedures should be clear and concise, with specific instructions for each step to ensure a prompt and effective response.

VII. Testing and Maintenance

  • Testing Procedures

  • Maintenance Procedures

  • Review and Update Procedures

This section of the plan is critical to ensure that an organization can effectively respond to disruptions and quickly resume its essential functions.

Testing procedures may include scenarios such as natural disasters, cyber-attacks, and other potential risks. The testing procedures should include clear objectives, testing scenarios, roles and responsibilities, and evaluation criteria to assess the effectiveness of the plan.

The Maintenance Procedures detail the steps necessary to keep the BCP up-to-date and relevant.

The Review and Update Procedures describe how the BCP will be reviewed and updated regularly to ensure its continued effectiveness. This may involve conducting a review of the plan on a regular basis or after significant changes to the organization’s operations or threats.

What should a business continuity plan checklist include?

Organizations looking to develop a BCP have more than a few things to think through and consider. Variables such as the size of the organization, its IT infrastructure, personnel, and resources all play a significant role in developing a continuity plan. Remember, each crisis is different, and each organization will have a view on handling it according to all the variables in play. However, all business continuity plans will include a few elements in one way or another.

  • Clearly defined areas of responsibility

    A BCP should define specific roles and responsibilities for cases of emergency. Detail who is responsible for what tasks and clarify what course of action a person in a specific position should take. Clearly defined roles and responsibilities in an emergency event allow you to act quickly and decisively and minimize potential damage.

  • Crisis communication plan

    In an emergency, communication is vital. It is the determining factor when it comes to crisis handling. For communication to be effective, it is critical to establish clear communication pipelines. Furthermore, it is crucial to understand that alternative communication channels should not be overlooked and outlined in a business continuity plan.

  • Recovery teams

    A recovery team is a collective of different professionals who ensure that business operations are restored as soon as possible after the organization confronts a crisis.

  • Alternative site of operations

    Today, when we think of an incident in a business environment, we usually think of something related to cybersecurity. However, as discussed earlier, a BCP covers many possible disasters. In a natural disaster, determine potential alternate sites where the company could continue to operate.

  • Backup power and data backups

    Whether a cyber event or a real-life physical event, ensuring that you have access to power is crucial if you wish to continue operations. In a BCP, you can often come across lists of alternative power sources such as generators, where such tools are located, and who should oversee them. The same applies to data. Regularly scheduled data backups can significantly reduce potential losses incurred by a crisis event.

  • Recovery guidelines

    If a crisis is significant, a comprehensive business continuity plan usually includes detailed guidelines on how the recovery process will be carried out.

Business continuity planning steps

An essential guide to the HIPAA Minimum Necessary Standard (1)

Here are some general guidelines that an organization looking to develop a BCP should consider:

Analysis

A business continuity plan should include an in-depth analysis of everything that could negatively affect the overall organizational infrastructure and operations. Assessing different levels of risk should also be a part of the analysis phase.

Design and development

Once you have a clear overview of potential risks your company could face, start developing a plan. Create a draft and reassess it to see if it takes into account even the smallest of details.

Implementation

Implement BCP within the organization by providing training sessions for the staff to get familiar with the plan. Getting everyone on the same page regarding crisis management is critical.

Testing

Rigorously test the plan. Play out a variety of scenarios in training sessions to learn the overall effectiveness of the continuity plan. By doing so, everyone on the team will be closely familiar with the business continuity plan’s guidelines.

Maintenance and updating

Because the threat landscape constantly changes and evolves, you should regularly reassess your BCP and take steps to update it. By making your continuity plan in tune with the times, you will be able to stay a step ahead of a crisis.

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A comprehensive business continuity plan is vital for the entire organization’s security posture. However, in a perfect world, you wouldn’t have to use it. This is where NordPass Business can help.

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With NordPass Business, your team will have a single secure place to store all work-related passwords, credit cards, and other sensitive information. Accessing all the data stored in NordPass is quick and easy, which allows your employees not to be distracted by the task of finding the correct passwords for the correct account.

In cyber incidents, NordPass Business ensures that company credentials remain secure at all times. Everything stored in the NordPass vault is secured with advanced encryption algorithms, which would take hundreds of years to brute force.

If you are interested in learning more about NordPass Business and how it can fortify corporate security, do not hesitate to book a demo with our representative.

FAQs

What is the minimum necessary standard rule in HIPAA? ›

The minimum necessary standard requires covered entities to evaluate their practices and enhance safeguards as needed to limit unnecessary or inappropriate access to and disclosure of protected health information.

What does it mean when 3 HIPAA includes the minimum necessary standard essentially? ›

The Minimum Necessary Standard, which can be found under the umbrella of the Privacy Rule, is a requirement that covered entities take all reasonable steps to see to it that protected health information (PHI) is only accessed to the minimum amount necessary to complete the tasks at hand.

What is the minimum necessary standard in HIPAA quizlet? ›

The minimum necessary rule in HIPAA is the privacy rule. The minimum required standard requires that protected health information (PHI) may not be used or disclosed when it is not necessary to perform functions that include treatment, payment, and healthcare operations.

What is the HIPAA security Rule Guide? ›

General Rules
  • Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit;
  • Identify and protect against reasonably anticipated threats to the security or integrity of the information;
  • Protect against reasonably anticipated, impermissible uses or disclosures; and.

Which of the following is an exception to the HIPAA minimum necessary standard? ›

Are There Exceptions to the HIPAA Minimum Necessary Standard? The minimum necessary standard does not apply to the following: Disclosures to or requests by a health care provider for treatment purposes. Disclosures to the individual who is the subject of the information.

How is minimum standard best defined in relation to HIPAA privacy rules? ›

The HIPAA Minimum Necessary Standard is a component of the HIPAA Privacy Rule. It states that covered entities must make reasonable efforts to ensure minimum access to physical or electronically protected health information.

What is one of the four standards of HIPAA? ›

The HIPAA Security Rule Standards and Implementation Specifications has four major sections, created to identify relevant security safeguards that help achieve compliance: 1) Physical; 2) Administrative; 3) Technical, and 4) Policies, Procedures, and Documentation Requirements.

What is the minimum necessary rule? ›

How Does The Minimum Necessary Rule Work? The HIPAA Minimum Necessary rule requires that covered entities take all reasonable efforts to limit the use or disclosure of PHI by covered entities and business associates to only what is necessary.

What is the HIPAA security Rule integrity requirement? ›

The Integrity standard requires a covered entity to: “Implement policies and procedures to protect electronic protected health information from improper alteration or destruction.” EPHI that is improperly altered or destroyed can result in clinical quality problems for a covered entity, including patient safety issues.

What is HIPAA compliance checklist? ›

What is a HIPAA compliance checklist? A HIPAA compliance checklist is a resource organizations use to understand the steps involved in achieving and maintaining HIPAA compliance. With a HIPAA compliance checklist, organizations can also discover how to create safeguards that protect their PHI.

What is not required by HIPAA minimum necessary rule quizlet? ›

The minimum necessary standard does not apply to the following : Disclosures to or requests by a health care provider for treatment purposes. Disclosures to the individual who is the subject of the information. Uses or disclosures made pursuant to an individual's authorization.

What does HIPAA's minimum necessary and related standards require of healthcare workers quizlet? ›

What does HIPAA's "minimum necessary" and related standards require of healthcare workers? Use or disclose only the minimum necessary amount of health information to accomplish a task. HIPAA's "incidental uses and disclosures" provision excuses deviations from the minimum necessary standard.

Which of the following are not required to comply with HIPAA? ›

Who Is Not Required to Follow These Laws
  • Life insurers.
  • Employers.
  • Workers compensation carriers.
  • Most schools and school districts.
  • Many state agencies like child protective service agencies.
  • Most law enforcement agencies.
  • Many municipal offices.

What is the minimum necessary standard quizlet? ›

The minimum necessary standard limits uses, disclosures, and requests for PHI to the minimum necessary amount of PHI needed to carry out the intended purposes of the use or disclosure. The minimum necessary standard does not apply to disclosures to, or requests by, a health care provider for treatment purposes.

What are the 5 HIPAA standards? ›

HHS initiated 5 rules to enforce Administrative Simplification: (1) Privacy Rule, (2) Transactions and Code Sets Rule, (3) Security Rule, (4) Unique Identifiers Rule, and (5) Enforcement Rule.

What are the 4 main principles of medical ethics and how do they apply to HIPAA? ›

Medical ethics consists of four main principles, each of which affects HIPAA:
  • Autonomy. Patients have the right to make their own decisions regarding their healthcare.
  • Non-maleficence. ...
  • Beneficence. ...
  • Justice.
Jan 25, 2023

What is an example of the minimum necessary rule? ›

For example, let's say a clinic has five medical providers. Only one of the providers is treating you (the patient). Per the HIPAA Minimum Necessary Rule, only the medical provider that is providing your treatment should have access to your patient records.

What is beyond the minimum necessary? ›

An amount beyond the minimum necessary is called the margin.

What is the appropriate and necessary rule? ›

Necessary and appropriate means that a strong rational basis exists for concluding that a prerequisite or corequisite is reasonably needed to achieve the purpose that it purports to serve. This standard does not require absolute necessity.

What makes a HIPAA violation? ›

A criminal HIPAA violation is when a covered entity, business associate, or a member of either´s workforce has wrongfully and knowingly accessed, obtained, or transmitted Protected Health Information without authorization for a purpose prohibited by §1320d-6 of the Social Security Act.

What is the most important rule in HIPAA? ›

The most important part of the HIPAA Act states that you must keep personally identifiable patient information secure and private. This provision has made electronic health records safer for patients. However, it's also imposed several sometimes burdensome rules on health care providers.

What are the 5 code sets approved by HIPAA? ›

HIPAA Code Sets
  • ICD-10 – International Classification of Diseases, 10th edition.
  • Health Care Common Procedure Coding System (HCPCS)
  • CPT-Current Procedure Terminology.
  • CDT – Code on Dental Procedures and Nomenclature.
  • NDC – National Drug Codes.
Apr 25, 2022

What are the 5 most common violations to the HIPAA privacy Rule? ›

5 Most Common HIPAA Privacy Violations
  • Losing Devices. In the last decade, over 800 device loss or theft incidents have been reported. ...
  • Getting Hacked. ...
  • Employees Dishonestly Accessing Files. ...
  • Improper Filing and Disposing of Documents. ...
  • Releasing Patient Information After the Authorization Period Expires.

What patient right is most often violated? ›

Examples of Common Patient Rights Violations include:
  • Failing to provide sufficient numbers of staff. ...
  • Failing to provide quality care.
  • Failing to provide proper nursing services.
  • Abandoning the patient.
  • Isolating the patient.
  • Failing to treat the patient with dignity or respect.

What is one example of a HIPAA violation? ›

Complex examples of HIPAA violations

According to HIPAA, patients have a right to their medical records within 30 days of a request; failure to provide them is a HIPAA violation. Losing a device or record that exposes patient records to unauthorized actors is also a HIPAA violation.

What identifiers violate HIPAA? ›

The 18 HIPAA Identifiers
  • Name.
  • Address (all geographic subdivisions smaller than state, including street address, city county, and zip code)
  • All elements (except years) of dates related to an individual (including birthdate, admission date, discharge date, date of death, and exact age if over 89)
  • Telephone numbers.
Nov 1, 2021

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