An information security team’s designated role is to implement an information security policy

Security Policies

1. Personal Hospital Device Policy
   • Description: Defines acceptable use of hospital-owned devices (laptops, tablets, mobile phones).
   • Justification: Prevents unauthorized access, malware infections, and data breaches.
   • Content:
     • Mandatory encryption.
     • Regular software updates.
     • Prohibition of unauthorized software installation.
     • Guidelines for device security in public places.
     • Policy for reporting lost or stolen devices.
2. Confidential Data Security Policy
   • Description: Outlines procedures for handling and protecting patient health information (PHI) and other sensitive data.
   • Justification: Comply with HIPAA regulations and protect patient privacy.
   • Content:
     • Data classification and labeling.
     • Access control measures.
     • Secure data transmission protocols.
     • Data retention and disposal procedures.
     • Policy regarding portable data storage devices.
3. Password Management Policy
   • Description: Establishes requirements for creating, storing, and changing passwords.
   • Justification: Prevents unauthorized access to systems and data.
   • Content:
     • Minimum password length and complexity.
     • Regular password changes.
     • Prohibition of password sharing.
     • Guidelines for secure password storage.
     • Multi factor authentication enforcement.
4. Data Transfer Policy
   • Description: Defines acceptable methods for transferring data internally and externally.
   • Justification: Prevents unauthorized data disclosure and ensures secure data exchange.
   • Content:
     • Approved data transfer methods (e.g., secure file transfer protocol, encrypted email).
     • Restrictions on transferring sensitive data via unencrypted channels.
     • Guidelines for data transfer to external parties.
5. Remote Access Policy
   • Description: Governs remote access to hospital networks and systems.
   • Justification: Ensures secure remote access for telehealth and mobile staff.
   • Content:
     • VPN requirements.
     • Multi-factor authentication.
     • Device security requirements for remote access.
     • Monitoring and logging of remote access activity.
6. Email Policy
   • Description: Defines acceptable use of hospital email systems.
   • Justification: Prevents phishing attacks, malware distribution, and data leaks.
   • Content:
     • Guidelines for email content and attachments.
     • Restrictions on sending sensitive information via email.
     • Procedures for reporting suspicious emails.
     • Policy on personal email usage on work devices.
7. Backup Policy
   • Description: Outlines procedures for backing up critical data and systems.
   • Justification: Ensures data recovery in the event of a disaster or system failure.
   • Content:
     • Backup frequency and retention policies.
     • Off-site backup storage.
     • Regular backup testing.
     • Disaster recovery plan.
8. VPN Policy
   • Description: Standards for VPN usage.
   • Justification: Protects the data transmitted over a public network.
   • Content:
     • Mandatory use of hospital provided VPN client.
     • Restrictions on Split tunneling.
     • Policy on personal device usage of the VPN.
9. Acceptable Use Policy (AUP)
   • Description: Defines acceptable use of hospital IT resources.
   • Justification: Prevents misuse of IT resources and ensures network security.
   • Content:
     • Restrictions on unauthorized access and use.
     • Guidelines for internet and email usage.
     • Prohibition of illegal or unethical activities.
10. Incident Response Policy
    • Description: Outlines procedures for responding to security incidents.
    • Justification: Minimizes the impact of security incidents and ensures timely recovery.
    • Content:
      • Incident reporting procedures.
      • Incident response team roles and responsibilities.
      • Incident containment and eradication procedures.
      • Post-incident review and analysis.
11. Physical Security Policy
    • Description: Measures to protect physical access to hospital facilities and IT infrastructure.
    • Justification: Prevents unauthorized physical access to sensitive areas.
    • Content:
      • Access control systems (e.g., key cards, biometric scanners).
      • Surveillance systems.
      • Visitor management procedures.
      • Server room security.
12. Periodical Review of Security Standards
    • Description: Process for periodic review of all security standards.
    • Justification: Ensures security standards remain up to date with new threats.
    • Content:
      • Set schedule for review.
      • Process for updating standards.
      • Communication plan for updated standards.
13. Disciplinary Actions Policy
    • Description: Consequences for violating security policies.
    • Justification: Deterrence and enforcement of security standards.
    • Content:
      • Range of disciplinary actions (e.g., warnings, suspension, termination).
      • Procedures for investigating and documenting policy violations.
      • Process for appealing disciplinary actions.

III. Security Policy Testing Methodology

• Vulnerability Scanning and Penetration Testing:
  • Justification: This methodology provides a comprehensive assessment of the hospital’s security posture by identifying vulnerabilities in systems and networks and simulating real-world attacks.
  • Process:
    • Vulnerability scanners are used to identify known vulnerabilities in software and hardware.
    • Penetration testers simulate attacks to identify weaknesses in security controls and assess the effectiveness of incident response procedures.
    • The results of the testing are used to prioritize remediation efforts and improve security controls.
    • This methodology also allows for testing of employee security awareness, via phishing simulations.
  • This methodology also allows for testing of the physical security controls.