Risk Management Policy (SEC-POL-003)

1. Objective

The objective of this policy is to establish a comprehensive risk management framework for identifying, assessing, treating, and monitoring information security risks across [Company Name]. This policy ensures that security risks are systematically managed to protect the confidentiality, integrity, and availability of information assets, particularly electronic Protected Health Information (ePHI), and to maintain compliance with regulatory requirements while supporting business objectives.

2. Scope

This policy applies to all [Company Name] workforce members, contractors, and third parties. It encompasses all information assets, systems, processes, and facilities owned, operated, or managed by [Company Name], including cloud services, third-party systems, and remote work environments. This policy covers all types of information security risks, including cybersecurity threats, operational risks, compliance risks, and business continuity risks.

3. Policy

  • [Company Name] shall implement and maintain a systematic risk management process that is integrated into all business activities and decision-making processes.

3.1 Risk Management Framework

  • [Company Name] shall establish and maintain a formal risk management framework based on industry best practices and regulatory requirements.

  • The risk management process shall follow a continuous cycle of identification, assessment, treatment, monitoring, and review.

  • Risk management activities shall be documented, consistent, and repeatable across the organization.

  • The framework shall be reviewed annually and updated as needed to reflect changes in the business environment, threat landscape, or regulatory requirements.

  • Risk management shall be integrated into strategic planning, project management, system development, and vendor management processes.

3.2 Risk Identification

  • [Company Name] shall proactively identify information security risks through multiple sources and methods.

  • Comprehensive risk assessments shall be conducted at least annually and whenever significant changes occur to systems, processes, or the business environment.

  • Threat intelligence sources shall be monitored to identify emerging risks and attack vectors relevant to the healthcare industry.

  • Vulnerability scanning shall be conducted at least quarterly for external-facing systems and annually for internal systems. External penetration testing shall be conducted at least annually.

  • Business process reviews shall be conducted to identify operational and procedural risks.

3.2.1 Penetration Testing and Vulnerability Assessment Implementation

  • [Company Name] shall implement comprehensive penetration testing and vulnerability assessment processes as follows:

  • Annual Penetration Testing Plan: The Information Security Officer shall develop an annual penetration testing plan identifying scope, methodology, timeline, and resource requirements for comprehensive security assessment.

  • Third-Party Testing Providers: Qualified third-party penetration testing vendors with [Required Certifications, e.g., CISSP, CEH, OSCP] and healthcare industry experience shall be engaged for testing activities.

  • Testing Methodology: Penetration testing shall include:
    • Pre-testing reconnaissance shall be conducted to identify external-facing systems, network ranges, and application attack surfaces.
    • Automated vulnerability scanning using [Scanning Tools, e.g., Nessus, Qualys, OpenVAS] shall be performed across all in-scope systems.
    • Network penetration testing shall be conducted including external perimeter testing, internal network lateral movement, and wireless network security assessment.
    • Web application security testing using [Testing Methodology, e.g., OWASP Testing Guide] shall be performed for all applications handling sensitive data.
    • Social engineering assessment shall be conducted including phishing simulation, physical security testing, and employee security awareness validation.
    • Cloud infrastructure security testing shall be performed including IAM controls, storage security, network configurations, and container security.

  • Vulnerability Documentation: All identified vulnerabilities shall be documented with risk ratings using [Risk Rating System, e.g., CVSS v3.1] and exploitation evidence.

  • Remediation Requirements: Critical and high-risk vulnerabilities shall be remediated within [Duration, e.g., 30 days] of testing completion, medium-risk vulnerabilities within [Duration, e.g., 90 days], and low-risk vulnerabilities within [Duration, e.g., 180 days].

  • Validation Testing: Validation testing shall be conducted to confirm successful remediation of all critical and high-risk vulnerabilities.

  • Quarterly Vulnerability Assessments: Automated vulnerability assessments shall be conducted quarterly with monthly scan result reviews for ongoing security validation.

  • Targeted Testing: Penetration testing shall be performed within [Duration, e.g., 30 days] of significant system changes, new application deployments, or security incidents.

  • Risk identification shall consider internal and external threats, including but not limited to:
    • Cybersecurity threats (malware, phishing, unauthorized access) shall be identified and assessed for organizational impact.
    • Natural disasters and environmental hazards shall be evaluated for their potential impact on information systems and business operations.
    • Human error and insider threats shall be considered as potential sources of information security risks.
    • Technology failures and system outages shall be assessed for their impact on data availability and business continuity.
    • Regulatory and compliance changes shall be monitored and evaluated for their impact on organizational risk posture.
    • Third-party and vendor risks shall be identified and assessed as part of the comprehensive risk management program.

3.3 Risk Assessment and Analysis

All identified risks shall be analyzed to determine their potential impact and likelihood of occurrence.

  • Risk assessment shall consider both inherent risk (before controls) and residual risk (after controls are applied).

  • Impact assessment shall evaluate potential consequences across multiple dimensions:
    • Financial impact (direct costs, regulatory fines, business disruption) shall be quantified where possible to support risk-based decision making.
    • Operational impact (service disruption, productivity loss) shall be assessed for its effect on business operations and service delivery.
    • Reputational impact (customer trust, market confidence) shall be evaluated for its potential long-term consequences to organizational standing.
    • Regulatory impact (compliance violations, sanctions) shall be assessed for potential legal and regulatory consequences.
    • Patient safety and privacy implications shall be evaluated for their impact on healthcare delivery and regulatory compliance.
  • Likelihood assessment shall consider:
    • Threat actor capabilities and motivations shall be evaluated based on available threat intelligence and industry analysis.
    • Asset vulnerabilities and exposure shall be assessed through vulnerability scanning and security assessments.
    • Effectiveness of existing controls shall be evaluated through testing, monitoring, and audit activities.
    • Historical incident data and industry trends shall be analyzed to inform likelihood assessments and improve accuracy.
  • Risk levels shall be determined using a standardized risk matrix. The criteria for impact, likelihood, and the resulting risk levels (High, Medium, Low) shall be formally documented and approved by the Information Security Committee.

3.4 Risk Treatment

  • [Company Name] shall implement appropriate risk treatment strategies based on risk levels and business priorities.

  • Risk treatment options include:
    • Accept: Acknowledge and monitor risks that fall within acceptable tolerance levels shall be documented with clear justification and approval.
    • Avoid: Eliminate the risk by discontinuing or modifying activities shall be considered when risks exceed organizational tolerance.
    • Mitigate: Implement controls to reduce likelihood or impact shall be the primary approach for managing significant risks.
    • Transfer: Share or transfer risk through insurance, contracts, or outsourcing shall be utilized where appropriate and cost-effective.

  • High-risk items shall be addressed with priority and escalated to executive leadership for treatment decisions.

  • Risk treatment plans shall include:
    • Specific actions and controls to be implemented shall be clearly defined with measurable objectives and outcomes.
    • Responsible parties and timelines shall be assigned to ensure accountability and timely implementation.
    • Resource requirements and budget allocations shall be identified and approved through appropriate organizational processes.
    • Success criteria and monitoring measures shall be established to evaluate the effectiveness of risk treatment activities.
  • The effectiveness of risk treatments shall be monitored and measured regularly.

3.5 Risk Monitoring and Review

  • [Company Name] shall continuously monitor the risk environment and the effectiveness of risk treatments.

  • A formal risk register shall be maintained to track all identified risks, their assessments, treatments, and current status.

  • Risk levels shall be reviewed quarterly or when significant changes occur.

  • Key risk indicators (KRIs) shall be established and monitored to provide early warning of increasing risk levels.

  • Regular reports on risk status and trends shall be provided to executive leadership and the Information Security Committee.

  • Annual risk assessment reviews shall validate the continued relevance of identified risks and assess the effectiveness of the overall risk management program.

3.6 Risk Communication and Reporting

Risk information shall be communicated effectively to all relevant stakeholders to support informed decision-making.

  • Risk reporting shall be tailored to the audience, with executive summaries for leadership and detailed technical reports for operational teams.

  • Critical risks and significant risk changes shall be escalated immediately to appropriate management levels.

  • Risk communication shall include:

    • Current risk landscape and trends shall be reported to provide situational awareness to stakeholders.
    • Status of risk treatment activities shall be communicated to track progress and identify issues requiring attention.
    • Emerging threats and vulnerabilities shall be shared to enable proactive risk management and response planning.
    • Recommendations for risk mitigation shall be provided to support evidence-based decision making.
    • Compliance and regulatory implications shall be communicated to ensure awareness of legal and regulatory requirements.

3.7 Third-Party Risk Management

Risks associated with third-party vendors, business associates, and service providers shall be assessed and managed as part of the overall risk management program.

  • Due diligence assessments shall be conducted before engaging third parties that will access, process, or store company information.

  • Contractual agreements shall include specific security requirements and risk allocation provisions.

  • Ongoing monitoring of third-party security posture shall be conducted through security questionnaires, audits, and performance reviews.

  • Third-party incidents and security events shall be tracked and incorporated into risk assessments.

3.8 Business Continuity and Operational Risk

Risk management shall include consideration of business continuity and operational resilience requirements.

  • Business impact assessments (BIAs) shall be conducted to identify critical business functions and acceptable downtime limits.

  • Single points of failure shall be identified and addressed through redundancy or alternative arrangements.

  • Disaster recovery and business continuity plans shall be developed based on risk assessment results.

  • Regular testing of continuity plans shall be conducted to validate their effectiveness.

4. Standards Compliance

This policy is designed to comply with and support the following industry standards and regulations.

Policy Section Standard/Framework Control Reference
All HITRUST CSF v11.2.0 17.a - Risk Management Program
3.1 HITRUST CSF v11.2.0 17.b - Risk Management Framework
3.2, 3.3 HITRUST CSF v11.2.0 17.c - Risk Assessment Process
3.2.1 HITRUST CSF v11.2.0 07.a - Vulnerability Management
3.2.1 HITRUST CSF v11.2.0 07.b - Vulnerability Assessment
3.2.1 HITRUST CSF v11.2.0 07.c - Vulnerability Remediation
3.2.1 HITRUST CSF v11.2.0 08.b - Network Security Testing
3.4, 3.5 HITRUST CSF v11.2.0 17.d - Risk Treatment
3.6 HITRUST CSF v11.2.0 17.e - Risk Monitoring and Review
3.7 HITRUST CSF v11.2.0 14.b - Third Party Risk Assessment
3.8 HITRUST CSF v11.2.0 16.b - Business Impact Analysis
All HIPAA Security Rule 45 CFR § 164.308(a)(1)(ii)(A) - Conduct risk assessments
All HIPAA Security Rule 45 CFR § 164.308(a)(1)(ii)(B) - Implement security measures
3.3 HIPAA Security Rule 45 CFR § 164.308(a)(1)(ii)(A) - Periodic risk assessment
3.2.1 HIPAA Security Rule 45 CFR § 164.308(a)(8) - Evaluation
All SOC 2 Trust Services Criteria CC3.1 - Risk Assessment Process
3.2, 3.3 SOC 2 Trust Services Criteria CC3.2 - Risk Identification
3.4, 3.5 SOC 2 Trust Services Criteria CC3.3 - Risk Mitigation
3.6 SOC 2 Trust Services Criteria CC3.4 - Risk Assessment Updates
3.2.1 SOC 2 Trust Services Criteria CC7.1 - System Security
3.2.1 SOC 2 Trust Services Criteria CC8.1 - Change Management
3.7 HIPAA Security Rule 45 CFR § 164.314(a)(1) - Business Associate contracts
All SOC 2 Trust Services Criteria CC3.1 - Risk Assessment Process
3.2, 3.3 SOC 2 Trust Services Criteria CC3.2 - Risk Identification and Analysis
3.4 SOC 2 Trust Services Criteria CC3.3 - Risk Mitigation Activities
3.5 SOC 2 Trust Services Criteria CC3.4 - Risk Monitoring Activities
3.8 SOC 2 Trust Services Criteria A1.1 - Availability and Business Continuity
All ISO/IEC 27001:2022 A.5.2 - Information security risk management
3.2.1 NIST SP 800-115 Technical Guide to Information Security Testing

5. Definitions

  • Business Impact Assessment (BIA): Analysis to identify and evaluate potential impacts resulting from business disruption.

  • Inherent Risk: The level of risk that exists before any controls or mitigation measures are applied.

  • Key Risk Indicators (KRIs): Metrics that provide early warning signals of increasing risk exposure.

  • Residual Risk: The level of risk remaining after controls and mitigation measures have been applied.

  • Risk Appetite: The level of risk that an organization is willing to accept in pursuit of its objectives.

  • Risk Assessment: The systematic process of identifying, analyzing, and evaluating risks.

  • Risk Register: A document that records identified risks, their analysis, and risk response plans.

  • Risk Tolerance: The acceptable level of variation around risk appetite.

  • Threat Intelligence: Information about current and emerging security threats and vulnerabilities.

6. Responsibilities

Role Responsibility
Executive Leadership Formally document, approve, and annually review the company’s risk appetite and tolerance levels. Approve risk treatment strategies for high-risk items. Provide resources for risk management activities.
Security Officer Own and maintain the risk management program. Conduct risk assessments and coordinate risk treatment activities. Report risk status to leadership. Oversee penetration testing and vulnerability assessment programs.
Information Security Committee Review and approve risk management policies and procedures. Oversee high-risk treatment decisions and resource allocation.
Risk Management Team Support risk assessment activities, maintain the risk register, and monitor risk treatment effectiveness.
IT Department Identify technical risks and vulnerabilities. Implement technical risk controls and participate in risk assessments.
Business Unit Managers Identify business risks within their areas. Participate in risk assessments and implement assigned risk treatments.
Asset/System Owners Assess risks for their assigned assets or systems. Implement and maintain appropriate risk controls.
All Workforce Members Report potential risks and security concerns. Comply with risk mitigation controls and procedures.
Audit and Compliance Team Validate risk assessment processes and control effectiveness. Ensure regulatory compliance requirements are addressed.
Third-Party Testing Vendors Conduct comprehensive penetration testing and vulnerability assessments according to defined methodologies and healthcare industry standards.
System Administrators Remediate identified vulnerabilities within specified timeframes based on risk level and impact assessment.