5 Ways a HIPAA Compliance Officer Can Support Your Facility
HIPAA compliance officers are members of the healthcare team who help a facility gain or maintain compliance with the complex rules set forth in the Health Insurance Portability and Accountability Act (HIPAA). This role is not only vital to the protection of a patient’s private health information, it’s also a legal requirement.
Most large hospitals have two compliance officers on staff: a privacy officer and a security officer, each with a distinct scope of work. Smaller facilities may appoint one compliance officer, or hire a consultant for the role.
Adhering to HIPAA’s privacy and security rules can be challenging for facilities, as the $144 million in civil penalties for violations shows. Ensuring that your team has the appropriate compliance officers on staff may do more than help you avoid fines. Let’s dig deeper into the compliance officer responsibilities, and discuss the ways they can contribute to financial security and patient outcomes at your facility.
What Does a HIPAA Compliance Officer Do in the Healthcare Field?
Within the context of healthcare, a compliance officer is responsible for creating, managing, and improving policies and procedures that facilities must implement to meet HIPAA standards. These officers must understand and work with the privacy rule and the security rule. They’re typically experts on all relevant HIPAA regulations, along with the ins and outs of a facility’s information systems.
Compliance Officer: Privacy Rule Duties
Under the HIPAA privacy rule, facilities are required to designate a privacy official (sometimes called a chief privacy officer, or CPO) who helps uphold rules regarding the appropriate access, exchange, and storage of protected health information (PHI). Depending on the size of a facility, this role may be established as a new position or assigned to existing administrative/IT staff.
Compliance Officer: Security Rule Duties
Under the security rule, facilities are required to appoint a HIPAA security officer who ensures the security of electronic protected health information (ePHI). While smaller facilities and clinics may be able to wrap this role in with the privacy officer responsibilities, large facilities handling high volumes of ePHI or overseeing complex ePHI workflows will need to install a full-time security officer. This individual may have a team working beneath them.
HIPAA Privacy Officer vs. Security Officer: What Are the Key Differences?
While these roles may sound similar, their duties are distinct. A CPO is responsible for ensuring compliance with federal and state health information privacy laws. Therefore, HIPAA privacy officer training involves extensive familiarity with the legal intricacies of HIPAA as they pertain to the privacy rule. These employees are also responsible for ensuring that staff members within their organization understand how to protect the confidentiality of health information and abide by the privacy rule at the clinical and executive levels.
In contrast, security officers work primarily to protect ePHI and ensure that the administrative, physical, and technical safeguards designated by the security rule are upheld. They’re typically given duties related to developing security policies, ensuring safe storage and transmission of ePHI, and preventing (or responding to) data breaches. They must have a thorough understanding of HIPAA, as well as information technology (IT) systems and data security best practices.
How Can a HIPAA Compliance Official Support Your Facility?
As a facility leader responsible for designating compliance officers for your facility, you may be wondering how exactly this role works to support your staff. Here are five specific ways that these professionals can benefit the workflow and quality of your facility’s HIPAA policies and procedures.
1. Create and Evaluate HIPAA Policies
One of the primary responsibilities of a HIPAA compliance official is to oversee all procedures that dictate PHI handling at a facility. Not only do these employees help create policies that meet regulatory requirements, but they also continually monitor the effectiveness of any HIPAA practices that are put in place.
For example, your privacy officer may conduct regular risk assessments to determine whether facility-level procedures actually meet all federal and state privacy rules. HIPAA compliance officer job descriptions typically detail the expectation for routine compliance audits.
Compliance officers also maintain records on past and current HIPAA procedures. This enables facilities to present any required documentation if they’re under review for a violation, or for other regulatory reasons such as a Joint Commission visit.
2. Improve Existing HIPAA Measures
Risk assessments also allow officers to promptly identify any shortcomings in facility-level policies and make appropriate changes for improvement. This ensures that any security risks are addressed to minimize the occurrence of preventable HIPAA violations.
At the federal level, HIPAA regulations are regularly amended to keep up with new data challenges arising from technological advances in the healthcare industry. The compliance officers on your team will be tasked with keeping up with these changes to ensure that facilities are retiring outdated practices and adopting the latest evidence-based procedures.
Security officers in particular have the challenging role of keeping up with evolving cyber security threats. Given that the average cost of a healthcare security breach in the U.S. is over $10 million, this area of expertise is crucial for preventing a fiscal crisis.
3. Ensure Facility-Wide HIPAA Compliance
For both security and privacy officers, HIPAA familiarity is essential to helping their organization provide high-quality care. Beyond optimizing existing policies and procedures, these professionals will also be responsible for ensuring that staff are working to uphold them. They regularly monitor activity of staff members who are accessing or using PHI to carry out their job duties. If any behavior strays away from HIPAA protocol, the compliance officer takes measures to enforce appropriate action.
Additionally, officers responsible for HIPAA compliance often lead initiatives in creating, conducting, or updating HIPAA compliance training for all staff members who handle PHI. HIPAA has specific criteria for who should receive training and what training sessions should include. Your team’s compliance officer will be responsible for keeping up with these guidelines to ensure that your facility is delivering all essential information to your staff.
4. Consult With Staff and Patients
As HIPAA experts, your privacy and security officers will have a breadth and depth of knowledge of all regulations surrounding patient confidentiality and privacy. This allows each of them to be a reliable point person if staff have concerns or questions about maintaining HIPAA compliance. For instance, if staff are unsure whether they should access a patient’s PHI, they can simply consult the CPO instead of sifting through HIPAA regulations, which can help increase the efficiency of the care team and lead to better outcomes for your patients.
5. Oversee Incident Reporting and Management
Even for facilities that employ an in-house security and privacy officer, HIPAA violations can occur either intentionally or unintentionally. Regardless of the cause, it’s important to have a clear system for reporting these cases so that any violations are resolved appropriately. The compliance officers on your team can create an effective system for incident reporting. In addition, they should analyze the reports to implement improvements so that similar incidents can be prevented.
Is Your Facility HIPAA Compliant?
Now that you’ve learned how a HIPAA compliance officer can support your facility and the patients in your care, you may be seeking more ways to improve your HIPAA policies. Want expert-backed information without having to sift through the research? Our trusted healthcare regulatory guides provide the facts you need, without the headaches.