Incident Response Framework and Team Management Policy (RES-POL-001)
1. Objective
The objective of this policy is to establish the foundational framework and team management structure for [Company Name]’s incident response program. This policy defines the overall incident response lifecycle, establishes incident classification criteria, creates the organizational structure for incident response team management, and ensures post-incident learning and improvement processes. By implementing a comprehensive incident response framework with clearly defined roles, responsibilities, and governance structures, [Company Name] ensures coordinated and effective response to security incidents while protecting electronic Protected Health Information (ePHI), maintaining regulatory compliance with HIPAA, HITECH, and SOC 2 requirements, and enabling continuous improvement of security capabilities.
2. Scope
This policy applies to all [Company Name] workforce members, contractors, third parties, and business associates involved in incident response planning, team management, or improvement activities. It encompasses the governance structure for all types of security incidents including data breaches, malware infections, unauthorized access, denial of service attacks, and physical security breaches. This policy establishes the framework that is implemented through the Security Event Detection and Monitoring Policy (RES-POL-003) and Incident Communication and Regulatory Compliance Policy (RES-POL-004), covering all information systems, applications, networks, devices, and data owned, operated, or managed by [Company Name].
3. Policy
[Company Name] shall maintain a comprehensive incident response framework that establishes clear governance structures, team management processes, and continuous improvement mechanisms to ensure effective coordination of all incident response activities across the organization, implemented through specialized policies for detection and monitoring (RES-POL-003) and communication and compliance (RES-POL-004).
3.1 Incident Response Framework
- [Company Name] shall implement a structured incident response process based on industry best practices and regulatory mandates.
3.1.1 Incident Response Lifecycle
The incident response process shall follow a systematic lifecycle approach based on the NIST Cybersecurity Framework (Prepare, Detect & Analyze, Contain/Eradicate/Recover, Post-Incident Activity).
- 1. Preparation:
- Development and at least annual review of the Incident Response Plan (IRP) shall be performed to maintain current readiness.
- Establishment and maintenance of a designated Incident Response Team (IRT) with clearly defined roles and responsibilities shall be implemented.
- Annual training and simulation exercises (e.g., tabletop exercises) for the IRT shall be conducted to ensure readiness, with outcomes documented for improvement tracking.
- Deployment and maintenance of tools and technologies mandated for incident detection, analysis, and response shall be performed.
- Maintenance of secure, out-of-band communication channels for the IRT shall be ensured for emergency communications.
- At least annual testing of incident response capabilities shall be conducted, with results documented and used to drive improvements.
- 2. Detection and Analysis:
- Continuous monitoring of information systems to detect security events shall be implemented and maintained.
- Initial triage of detected events to determine if a potential incident has occurred shall be performed promptly.
- Formal declaration of an incident and activation of the Incident Response Team (IRT) shall be executed according to established procedures.
- Initial impact and severity assessment to classify the incident according to the criteria in section 3.1.2 shall be completed.
- Establishment of a secure repository for evidence collection and chain of custody documentation shall be performed.
- Prioritization of response activities based on the incident classification shall be implemented.
- 3. Containment, Eradication, and Recovery:
- Execution of containment strategies to prevent the incident from spreading and to minimize further damage shall be performed immediately.
- Identification of the root cause and all affected systems shall be completed through systematic investigation.
- Eradication of the threat (e.g., removing malware, disabling breached accounts, patching vulnerabilities) shall be performed.
- Systematic recovery of affected systems and data from trusted sources shall be executed.
- Validation that systems are clean and secure before returning them to production shall be performed.
- Enhanced monitoring of recovered systems to ensure the threat has been fully removed shall be implemented.
- 4. Post-Incident Activity:
- Incident documentation and reporting shall be completed according to organizational standards.
- Lessons learned analysis and improvement recommendations shall be developed and implemented.
- Incident response plan updates shall be performed based on lessons learned.
- Stakeholder communication and follow-up shall be conducted as required.
- Legal and regulatory compliance activities shall be completed according to applicable requirements.
3.1.2 Incident Classification
All incidents shall be classified based on their severity and potential impact:
- Critical (P1) - Emergency Response Required:
- Confirmed data breach involving ePHI or large volumes of sensitive data shall be classified as Critical.
- Active compromise of critical systems affecting business operations shall be classified as Critical.
- Widespread malware infection or ransomware attack shall be classified as Critical.
- Suspected nation-state or advanced persistent threat (APT) activity shall be classified as Critical.
- Physical security breach affecting critical assets shall be classified as Critical.
- Response Time: Immediate response shall be required (within 15 minutes).
- High (P2) - Urgent Response Required:
- Unauthorized access to sensitive systems or data shall be classified as High.
- Malware infection on critical systems shall be classified as High.
- Denial of service attacks affecting business operations shall be classified as High.
- Suspected insider threat activity shall be classified as High.
- Social engineering attacks targeting executives or privileged users shall be classified as High.
- Response Time: Response shall be required within 1 hour.
- Medium (P3) - Standard Response Required:
- Unsuccessful attack attempts against critical systems shall be classified as Medium.
- Malware infection on non-critical systems shall be classified as Medium.
- Policy violations with potential security impact shall be classified as Medium.
- Suspicious network activity or anomalous behavior shall be classified as Medium.
- Physical security violations in non-critical areas shall be classified as Medium.
- Response Time: Response shall be required within 4 hours.
- Low (P4) - Routine Response Required:
- Security policy violations without immediate risk shall be classified as Low.
- Failed login attempts within normal thresholds shall be classified as Low.
- Spam or phishing emails reported by users shall be classified as Low.
- Minor physical security issues shall be classified as Low.
- Security awareness training opportunities shall be classified as Low.
- Response Time: Response shall be required within 24 hours.
3.2 Incident Response Team
A designated Incident Response Team (IRT) shall be established with clearly defined roles and responsibilities.
3.2.1 Core Team Members
- Incident Commander:
- Overall incident response coordination and decision-making authority shall be maintained.
- Communication with executive leadership and external stakeholders shall be performed.
- Resource allocation and escalation decisions shall be made as required.
- Post-incident review and improvement oversight shall be provided.
- Security Analyst:
- Technical investigation and analysis shall be conducted.
- Evidence collection and preservation shall be performed.
- Malware analysis and threat intelligence gathering shall be executed.
- System forensics and artifact examination shall be performed.
- System Administrator:
- System containment and isolation procedures shall be executed.
- System restoration and recovery activities shall be performed.
- Network security controls implementation shall be conducted.
- Infrastructure monitoring and maintenance shall be provided.
- Privacy Officer:
- HIPAA breach assessment and notification requirements shall be managed.
- Regulatory compliance coordination shall be performed.
- Patient notification and communication shall be conducted as required.
- Risk assessment for privacy violations shall be performed.
- Legal Counsel:
- Legal implications assessment and guidance shall be provided.
- Law enforcement coordination and communication shall be managed.
- Litigation hold and evidence preservation requirements shall be addressed.
- Regulatory notification and compliance support shall be provided.
- Communications Lead:
- Internal and external communication coordination shall be performed.
- Media relations and public communications shall be managed.
- Customer and stakeholder notification shall be conducted.
- Crisis communication management shall be provided.
3.2.2 Extended Team Members
Additional team members may be activated based on incident type and severity:
- Human Resources representative for insider threat incidents shall be engaged as needed.
- Facilities manager for physical security incidents shall be involved when required.
- Third-party forensics and investigation specialists shall be engaged for complex incidents.
- Public relations and crisis communication experts shall be involved for high-visibility incidents.
- External legal counsel and regulatory specialists shall be engaged as circumstances require.
- Business unit leaders and system owners shall be involved based on affected systems and operations.
3.3 Security Event Detection and Monitoring
All security event detection, monitoring, and initial reporting activities shall be implemented as defined in the Security Event Detection and Monitoring Policy (RES-POL-003). This includes automated detection systems, manual observation methods, event reporting procedures, and triage processes that determine when incident response activities should be activated.
3.4 Incident Response Procedures and Compliance
All incident response procedures, stakeholder communication, and regulatory compliance activities shall be implemented as defined in the Incident Communication and Regulatory Compliance Policy (RES-POL-004). This includes standardized response procedures, containment and recovery activities, HIPAA breach notification requirements, and comprehensive communication protocols with internal and external stakeholders.
3.5 Post-Incident Activities and Organizational Learning
Comprehensive post-incident activities shall ensure organizational learning and continuous improvement of the incident response framework.
3.7.1 Incident Documentation
- Incident Report Contents:
- Complete timeline of incident detection, response, and recovery shall be documented.
- Root cause analysis and contributing factors shall be identified and documented.
- Impact assessment including affected systems and data shall be completed.
- Response effectiveness evaluation and lessons learned shall be documented.
- Recommendations for security improvements and process enhancements shall be provided.
3.7.2 Lessons Learned and Improvement
- Post-Incident Review:
- Formal review meeting within [Timeframe, e.g., 2 weeks] of incident closure shall be conducted.
- Analysis of response effectiveness and areas for improvement shall be performed.
- Review of incident response plan adequacy and updates needed shall be completed.
- Evaluation of team performance and training requirements shall be conducted.
- Assessment of detection capabilities and monitoring effectiveness shall be performed.
- Process Improvement:
- Incident response procedures shall be updated based on lessons learned.
- Additional security controls to prevent similar incidents shall be implemented.
- Monitoring and detection capabilities shall be enhanced as needed.
- Training and awareness programs shall be improved based on findings.
- Business continuity and disaster recovery plans shall be updated as required.
4. Standards Compliance
5. Definitions
See Annex: Glossary
6. Responsibilities
| Role | Responsibility |
|---|---|
| Security Officer | Incident response framework and policies shall be developed, incident response team structure shall be maintained, incident response program shall be overseen, and compliance with regulatory requirements shall be ensured. |
| Incident Commander | Incident response activities shall be led, team efforts shall be coordinated, critical response decisions shall be made, stakeholder communication shall be managed, and effective incident management shall be ensured. |
| IT Security Team | Incident response framework implementation shall be supported, technical expertise to incident response team shall be provided, incident response tools and capabilities shall be maintained, and team training shall be participated in. |
| Privacy Officer | Coordination with incident response team on privacy-related incidents shall be performed, HIPAA compliance activities shall be supported, and incident response training and exercises shall be participated in. |
| Legal Counsel | Legal guidance for incident response framework shall be provided, incident response team during legal matters shall be supported, and incident response planning and training shall be participated in. |
| Executive Leadership | Strategic guidance and resources for incident response program shall be provided, incident response team authority shall be supported, and organizational commitment to incident response capabilities shall be ensured. |
| Human Resources | Incident response team with workforce-related incidents shall be supported, coordination with legal team on personnel matters shall be performed, and incident response training programs shall be participated in. |
| All Workforce Members | Incident response procedures shall be understood, incident response training shall be participated in, incident response activities shall be supported when requested, and incident response policies and procedures shall be followed. |