3. Policy Management Policy

CIRG implements policies and procedures to maintain compliance and integrity of data. The Security Officer and Privacy Officer are responsible for maintaining policies and procedures and assuring all CIRG workforce members, business associates, customers, and partners are adherent to all applicable policies. Previous versions of policies are retained to assure ease of finding policies at specific historic dates in time.

3.1 Applicable Standards

3.1.1 Applicable Standards from the HITRUST Common Security Framework

• 12.c - Developing and Implementing Continuity Plans Including Information Security

3.1.2 Applicable Standards from the HIPAA Security Rule

• 164.316(a) - Policies and Procedures
• 164.316(b)(1)(i) - Documentation

3.2 Maintenance of Policies

1. All policies are stored and up to date to maintain CIRG compliance with HIPAA, HITRUST, NIST, and other relevant standards. Updates and version control are done similar to source code control.
2. Policy update requests can be made by any workforce member at any time. Furthermore, all policies are reviewed annually by both the Security and Privacy Officer to assure they are accurate and up-to-date.
3. CIRG employees may request changes to policies using the following process:
4. The CIRG employee initiates a policy change request by sending an email to the Security and Privacy Officers. The change request may optionally include a GitHub pull request from a separate branch or repository containing the desired changes.
5. The Security Officer or the Privacy Officer is assigned to review the policy change request.
6. Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
7. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
8. If the policy change requires technical modifications to production systems, those changes are carried out by authorized personnel using CIRG’s change management process (§9.4).
9. All policies are made accessible to all CIRG workforce members. The current master policies are published at https://github.com/uwcirg/hipaa-policies.
   • The Security Officer communicates policy changes to all employees via email. These emails include a high-level description of the policy change using terminology appropriate for the target audience.
10. All policies, and associated documentation, are retained for 6 years from the date of its creation or the date when it last was in effect, whichever is later
    1. Version history of all CIRG policies is done via GitHub.
    2. Backup storage of all policies is done with Google Drive.
11. The policies and information security policies are reviewed and audited annually, or after significant changes occur to CIRG’s organizational environment. Issues that come up as part of this process are reviewed by CIRG management to assure all risks and potential gaps are mitigated and/or fully addressed.

Additional documentation related to maintenance of policies is outlined in §5.3.1.