Business Continuity Plan (BCP) – Phase 3

Business Continuity Plan (BCP) – Phase 3

Part 1: Issue-Specific Security Policies

NIST SP 800-12 Rev. 1 recommendations state that organizations need effective infosec policies to mitigate risks, comply with regulations, maintain operations, and safeguard information confidentiality, integrity, and accessibility (Cichonski et al., 2012). NIST proposes three types of information security policies, but issue-specific security policies (ISSPs) are the most significant because they address institutional challenges. This phase requires ABC Hospital System ISSP documents addressing issues outlined in “SP 800-61 Rev. 2.” Each ISSP document will include a problem statement, organizational position, application, role division and responsibility allocation scheme, compliance steps, contact points, and other relevant information. The following will be discussed:

Reporting and Communication Channels for Internal and External Stakeholders

Issue Statement: All stakeholders need reporting lines for internal or external purposes.

Organizational Position: ABC Hospital believes a transparent reporting system is needed to promptly address security incidents (Argaw et al., 2020).

Applicability: All ABC Hospital System employees and contracted service providers must follow this policy.

Roles and Responsibilities: Employees must report security incidents immediately, but the IT department will build communication channels.

Compliance: All ABC Hospital System workers must follow this policy when using the network.

Points of Contact: IT has assigned staff for specific security incidents, making it the main contact point.

Supplementary Information: All workers will get periodic training on the importance of these reporting routes.

Use of Personal Equipment on ABC Hospital’s Network (BYOD)

Issue Statement: ABC Hospital’s network must control personal device use to protect sensitive data.

Organizational Position: ABC Hospital acknowledges the ease of BYOD policies but believes strict restrictions are needed to reduce security risks.

Applicability: ABC Hospital’s network must be accessed by staff and authorized users using personal devices.

Roles and Responsibilities: IT should enforce BYOD standards, while employees must follow security requirements.

Compliance: All users, including those who have not registered their devices or installed software, must obey acceptable usage policies (Ahmed, 2022).

Points of Contact: The IT helpdesk will assist with BYOD policies and adherence.

Supplemental Information: Employees will receive BYOD best practices and security training to reduce network hazards.

Internet Access

Issue Statement: ABC Hospital’s network is vulnerable to malware, phishing, and other security threats from unrestricted internet access.

Organizational Position: ABC Hospital needs the Internet for commerce and a good exposure management system.

Applicability: ABC Hospital workers and those with internet access must follow this rule.

Roles and Responsibilities: Organizational internet users should follow IT department guidelines, such as accessing internal online pages.

Compliance: Internet usage rules must be followed to protect network security.

Points of Contact: The IT department will administer internet access at this institution.

Supplementary Information: This policy will include occasional audits and checks to verify Internet Policy Compliance and identify illegal actions.

Personal Use of Company Equipment

Issue Statement: Unauthorized personal usage of company equipment compromises security, productivity, and resource allocation.

Organizational Position: ABC Hospital prohibits personal use of firm assets to protect assets and improve efficiency.

Applicability: This policy applies to all ABC Hospital employees and authorized personnel who utilize equipment for work.

Roles and Responsibilities: Employees must not share corporate resources for non-business purposes, but the IT department must strictly enforce this policy for consultants.

Compliance: Violators may be warned, suspended, or fired.

Points of Contact: IT and HR will enforce and monitor these policies. Any employee who violates them will be disciplined according to process.

Supplementary Information: To educate employees about the risks of misused business property, such as computers, campaigns have been established.

Removal of Organizational Equipment from the Company’s Property

Issue Statement: Unauthorized equipment removal from company premises can cause asset loss, theft, and data misuse.

Organization’s Position: ABC Hospital prohibits unauthorized equipment removal from approved premises to prevent asset mismanagement or security breaches.

Applicability: This policy applies to all employees and authorized workers who handle organization equipment.

Roles and Responsibilities: The IT department should check compliance and follow up on any equipment movements, while employees intending to remove corporate property from this site must obtain authority (U.S. Department of Health & Human Services, 2022).

Compliance: Violators may face disciplinary action and damages/losses.

Points of Contact: The IT department and facilities management enforce this regulation when office equipment is unauthorized removed.

Supplementary Information: Asset tagging, inventory management, and access control will be implemented to ensure accountability for removing and preventing unlawful equipment.

Use of Unofficial Software

Issue Statement: Unofficial software can cause malware infestations, license violations, and compatibility concerns.

Organizational Position: ABC Hospital Network prohibits the use of non-official software on its unique devices to ensure security, compliance, and operational integrity.

Applicability: This policy covers all ABC Hospital employees and authorized people who install or use the software.

Roles and Responsibilities: Employees must get IT approval before installing applications on business hardware.

Compliance: Staff members who violate these guidelines may be disciplined by having their devices purged of unauthorized software.

Points of Contact: The IT helpdesk can answer questions regarding how to follow a rule during installation.

Supplementary Information: Regular software audits and vulnerability assessments will discover and remove unauthorized software installs from ABC Hospital’s IT environment (Ayatollahi & Shagerdi, 2017).

Design and Development of an Information Security Awareness and Training Program for the Organization

Issue Statement: Employee awareness and training are essential to a successful cyber security plan to reduce human errors, raise security awareness, and foster vigilance.

Organizational Position: ABC Hospital recognizes the need to engage in comprehensive information safety awareness programs that teach employees how to protect personal information to avoid security risks.

Applicability: This policy applies to ABC Hospital employees, contractors, and stakeholders.

Roles and Responsibilities: The HR and IT departments plan, create, and execute ISSPs that meet the organization’s risk profile and demands.

Compliance: To ensure that all staff members are informed and capable of responding to information security issues, they must attend regular training to receive feedback on their knowledge. Compliance requires all staff attendance at information security awareness and training courses and quarterly assessments of retention and program efficiency.

Points of Contact: The HR department will coordinate with IT personnel to distribute necessary information.

Supplementary Information: Information security awareness workshops will cover data protection best practices, phishing awareness, password hygiene, and incident reporting.

ABC Hospital System BCPs must include security policy creation and execution. This approach addresses safety problems through systematic ISSP writings for risk mitigation, legal compliance, and uninterrupted operations. ABC Hospital System may promote security knowledge and resistance to evolving cyber threats by conveying clear rules, establishing roles and responsibilities, and maintaining training/awareness.

Part 2: Legal Standard Operating Policies and Procedures for Business Continuity

In today’s fast-changing business world, many issues might impair operations. Businesses need effective business continuity plans (BCPs) to withstand such incidences. Legal standard operating procedures are essential to any BCP. These policies help firms comply with laws and continue operations during emergencies (Božić, 2023). This section describes ABC Hospital’s legal standard operating procedures for fire evacuation, ransomware attacks, power outages, pandemics, workplace violence, data breaches, severe weather events, and cybersecurity disasters.

Fire Evacuation Procedure

Industry Compliance: ABC Hospital follows all National Fire Protection Association (NFPA) and municipal fire safety laws.

Business Operations: In a fire emergency, the company is first in line to evacuate all employees safely without injury. This manual details how to handle such an emergency:

• Fire Alarm Activation: In case of a fire or fire alarm sound, activate the neighboring pull station to inform building residents promptly.
• All personnel and visitors must escape the building via the nearest exit. These escape route markers are throughout the facility and should be followed.
• Help Others: Physically disabled patients and visitors should be assisted during evacuation to ensure their safety. However, trained evacuation professionals should assist as needed.
• After leaving the facility, go outside to the assembly point at [insert location]. Employees must stay there until emergency responders tell them otherwise.
• Headcount: Department heads or assigned persons must headcount their team members to safely exit the premises.

Training and Awareness: Workers receive frequent training on fire evacuation strategy, including where fire exits are, how fire alarms function, and how to escape a building.

Disaster Recovery: ABC Hospital would conduct a thorough structural inspection after a fire evacuation to assess damage and determine how to restart normal operations as soon as practicable.

Incident Response: This team would contact emergency responders and manage evacuation to minimize loss in a fire emergency.

Ransomware Attack Response Plan

Industry Compliance: ABC Hospital follows all cybersecurity laws, including the Health Insurance Portability and Accountability Act (HIPAA) and the Payment Card Industry Data Security Standard (PCI DSS).

Business Operations: ABC Hospital should act quickly to minimize loss and disruption from ransomware attacks. The following response plan provides step-by-step instructions:

• IT must isolate vulnerable systems from the network as soon as it detects ransomware to prevent malware from spreading.
• Time is of the essence when the IT department notifies senior management, including the CISO and CIO, of these incidents.
• Containment and Remediation: IT should promptly mitigate ransomware infections to take corrective action. This may also require backup restoration, anti-malware solutions, and security fixes to prevent further attacks.
• During an attack, ABC Hospital must communicate clearly with key personnel. Report incident updates through official channels (Kuzminykh et al., 2021).
• Law Enforcement and Legal Compliance: This healthcare institution must notify police and regulatory authorities of such instances. Legal consultation and verification for ramifications are needed to comply with data protection laws.

Training and Awareness: All employees receive ongoing training on how to protect their personal information from cyberattacks, including phishing emails, malware installation, and other internet risks.

Disaster Recovery: After a ransomware assault, this company would examine its computer network security before taking further precautions. Saving data loss and restoring normalcy would be priorities.

Incident Response: The Incident Response Team will swiftly address ransomware issues, including engagement with law enforcement and regulatory entities.

Power Outage Contingency Protocol

Industry Compliance: ABC Hospital meets all OSHA and NFPA electrical safety and emergency preparedness criteria.

Business Operations: A blackout could affect operations and patient care. Power outages are handled as follows.

• Once power is off, designated people should assess the power failure range and identify important systems requiring rapid backup.
• Activate backup power generators for life-critical departments such as ICU, ER, and operating rooms.
• Patient Care: During power outages, continue patient care utilizing alternative sources of electricity. Medical gadgets and equipment must be closely monitored to guarantee normal operation.
• Contact: Maintain open contact with staff, patients, and visitors during blackouts to provide updates on the situation and electricity restoration efforts.
• To expedite electricity supply restoration, collaboration with local utility providers and emergency response organizations is crucial. Utility providers should update ABC Hospital about restoration timelines.

Training and Awareness: All employees receive training on what to do during a blackout, including how to turn on backup generators, how to handle electrical problems, and how to deliver healthcare in the dark.

Disaster Recovery: ABC Hospital will conduct a post-power loss analysis to identify areas for improvement before adopting resilience measures. Upgrades may include emergency generators and backup batteries.

Incident Response: The Incident Response Team will organize the organization’s power outage reaction. Resource allocation, external stakeholder communication, and recovery progress tracking are included.

Workplace Violence Protocol

Industry Compliance: ABC Hospital honors safety and violence prevention guidelines, including those established by OSHA and the Occupational Safety and Health Act (OSH Act).

Business Operations: Workplace violence endangers staff, visitors, and patients. The following steps address workplace violence:

• Employees must recognize verbal threats, physical hostility, and deadly weapons or firearms.
• Line workers should be trained to de-escalate conflicts and prevent violence—examples are active listening, empathy, and dispute settlement.
• Emergency Response: After an active threat or violence-related activity, personnel should shelter, call law police, and help.
• ABC Hospital will report workplace violence to the police. Police must act now to protect hospital staff and guests.

Training and Awareness: All employees learn how to recognize danger signs, calm stressful situations before they are wounded, and respond rapidly to workplace violence.

Disaster Recovery: ABC Hospital will assess its security and take further steps to protect visitors after the workplace terror incident. Installation of access control, surveillance cameras, or more security personnel is possible.

Incidence Response: The Incident Response Team (IRT) will support affected employees, conduct internal investigations, and correct future workplace violence situations.

Data Breach Response Plan

Industry Compliance: ABC Hospital follows data protection laws and regulations like HIPAA and the General Data Protection Regulation (GDPR).

Business Operations: Data breaches can compromise confidentiality, integrity, and availability. The following reaction strategy will help personnel handle this situation:

• Detection and Assessment: IT staff must promptly investigate suspected security breaches.
• IT personnel must respond quickly to control the intrusion and prevent unauthorized access to critical data. This may include disabling hacked accounts, restoring backup data, and adding security restrictions.
• ABC Hospital notifies affected persons, regulatory authorities, and stakeholders of the occurrence as required by law. Maintaining patient confidence requires timely, transparent communication about what happened.
• IT personnel must do a forensic investigation to determine the cause and extent of harm and gather evidence for criminal procedures.

Training and Awareness: Employees are trained on data protection best practices, including identifying breaches, reporting them, securing essential information, and verifying for privacy legislation compliance.

Disaster Recovery: After a breach at ABC Hospital, safety measures like certifying encryption protocols and increasing employee training will be taken to improve cyber security.

Incident Response: The Incident Response Team will investigate the data breach, notify affected parties and regulatory authorities, and take corrective action to prevent future breaches.

Severe Weather Emergency Procedure

Industry Compliance: ABC Hospital follows regulations established by the Federal Emergency Management Agency (FEMA) and municipal emergency preparedness and response regulations.

Business Operations: Hurricanes, tornadoes, and floods can pose significant threats to people, patients, and buildings. If this happens, the following steps are recommended:

• Risk Assessment: ABC Hospital regularly assesses potential dangers during severe weather events like hurricanes to minimize the operational effects.
• Emergency Communication: ABC Hospital sends timely communications during severe weather warnings or watches via email, SMS alerts, or public address systems.
• During extreme weather, personnel and patients follow a Shelter-in-Place Protocol to ensure safety within a building until normalcy returns. The trained will give instructions as needed.
• ABC Hospital must collaborate with regional disaster management authorities and first aid responders to prepare for severe weather emergencies. This may require patient evacuation, emergency medical teams, and community aid.

Training and Awareness: All staff are trained on severe weather emergency protocols, including recognizing danger signs, finding shelter, and resolving the crisis. Regular drills and training assess the company’s readiness and improve its response.

Disaster Recovery: After a major weather catastrophe, ABC Hospital will inspect facilities and infrastructure for damage or deficiencies. Restoring vital services and eliminating patient care disruptions should be prioritized throughout recovery.

Incident Response: In response to severe weather emergencies, the Incident Response Team will assess the impact, mobilize resources, including people power, and communicate with internal and external stakeholders to ensure quick and efficient action.

Lawful standard operating policies (SOPs) are essential for the continuity of operations during events and emergencies. ABC Hospital can respond effectively to fire evacuations, ransomware attacks, power outages, pandemics, workplace violence, data breaches, severe weather emergency conditions, and cyber security breakdowns while considering staff, patients, and visitors’ health.

Part 3: Incident Response Plan for ABC Hospital

ABC Hospital needs a good incident response plan (IRP) to handle emergencies that could compromise its operations or data. Based on “SP 800-61 Rev. 2: The Computer Security Incident Handling Guide”, this IRP covers ransomware attacks, power outages, and ISP problems, among others. Following NIST’s S.P. 800-34r1 seven-step paradigm, alternate sites can be created to restore important business functions after an extended business disruption (Pamungkas et al., 2023).

Ransomware Attack on One PC/User

1. Detection and Identification

ABC Hospital’s IT security systems will be monitored for suspicious behavior or ransomware indicators. IT staff will quickly analyze intrusion detection system warnings, antivirus software notifications, and user reports.

2. Containment

If a PC/user device is identified to have been attacked by ransomware in ABC Hospital, the affected device will be isolated from the rest of the network so that the malware cannot spread further.

3. Eradication

The IT security team will undertake an extensive scan and cleanup process to remove ransomware malware from the compromised device using antivirus software, malware removal tools, and system restores from backups (Sasaki et al., 2020).

4. Recovery

Securely stored offsite data backups shall be used to revert encrypted files and systems back to their previous state before any attacks occur. System patches and updates should also be deployed to mitigate vulnerabilities exploited by the ransomware.

5. Notification

The ransomware incident is rapidly reported to stakeholders, including regulatory authorities, executive management, and information technology personnel, showing the containment and remediation actions taken.

6. Post-Incident Analysis

A comprehensive post-incident analysis should investigate what might have led to this attack as well as evaluate the effectiveness of our incident response procedures so that necessary improvements can be initiated in order to prevent future occurrences.

7. Documentation and Reporting

Every detail of what happened during the ransomware attack, response actions taken, and lessons learned must be comprehensively documented for regulatory compliance, legal purposes, and internal review purposes accordingly.

Power Failure

1. Detection and Identification

In the case of a power failure in ABC Hospital, monitoring systems will alert IT personnel, causing immediate action by the facilities management team.

2. Containment

For the prevention of destruction or loss of data due to sudden power surges or fluctuations, critical systems and devices will be orderly powered down.

3. Mitigation

When there is no normal power supply, backup generators and UPSs would be used to maintain emergency lighting, life support systems like ventilation, and communication infrastructure.

4. Restoration

As soon as electricity is brought back, the facilities management staff will conduct an extensive check on electrical systems and equipment for safety measures and functionality prior to gradually restoring everything back to normalcy.

ISP Failure

1. Detection and Identification

In case of ISP failures/disruptions in network connectivity, ISPs have network monitoring setups that can detect and notify their IT staff if this happens, thus signaling a prospective service downtime.

2. Containment

The breakage extent should be established by the IT department while at the same time assessing how it affects critical business processes, after which they can deal with patient care concerns accordingly.

3. Mitigation

Alternative channels of communication, such as redundant ISP connections, mobile hotspots, or satellite internet services, could be activated to keep the link running without interruptions into vital systems/data.

4. Restoration

Working with the ISP provider to fast-track resolution efforts aimed at returning the network to its normal state swiftly is one way of avoiding downtime or disruption in hospital operations.

Establishing Alternative Sites for Critical Business Functions

In case the current business location becomes inaccessible for prolonged periods because of a disaster, ABC Hospital must plan alternative sites for critical business functions. This arrangement follows a 7-step model suggested in NIST SP 800-34r1 (Pamungkas et al., 2023):

1. Develop a Business Continuity Strategy – Prioritize essential functions according to their impacts on regulatory compliance and quality of patient care.
2. Conducting a Business Impact Analysis (BIA) – Evaluate implications for patient safety, revenue generation, and reputation after prolonged shutdowns.
3. Identify Recovery Requirements – Identify the resources, facilities, and infrastructure required to support critical business functions in alternative sites, such as IT systems, medical equipment, and personnel.
4. Establish Recovery Time Objectives (RTOs) and Recovery Point Objectives (RPOs) – Establish allowable thresholds for downtime and data loss to guide recovery efforts on key processes and systems.
5. Develop a Business Continuity Plan (BCP). This is the document that will detail step-by-step relocation procedures, including backup/restoration of data, staff mobilization, and communication channels for moving critical business functions into alternate sites.
6. Implementing and testing the BCP – It is important to regularly perform drills or exercises that measure the efficiency of BCP to determine whether it is ready for actual deployment in case a disaster occurs.
7. Maintaining and reviewing BCP: Reviewing and updating the BCP periodically, considering organizational changes, technology advances, and regulatory provisions, ensures its conformity with business goals while remaining current with industry trends.

By so doing, ABC Hospital can effectively deal with adverse events’ impact by adhering to these comprehensive incident response and business continuity measures, ensuring operational resilience even during disruptions.

References

Ahmed, N. B. (2022). Cybersecurity in the healthcare system: Evaluation and assessment of the cybersecurity readiness of mobile field hospital’s resilience (Doctoral dissertation, IMT-MINES ALES-IMT-Mines Alès Ecole Mines-Télécom).

Argaw, S. T., Troncoso-Pastoriza, J. R., Lacey, D., Florin, M. V., Calcavecchia, F., Anderson, D., Burleson, W., Vogel, J. M., O’Leary, C., Eshaya-Chauvin, B., & Flahault, A. (2020). Cybersecurity of hospitals: Discussing the challenges and working towards mitigating the risks. BMC Med Inform Decis Mak, 20(146). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333281/

Ayatollahi, H., & Shagerdi, G. (2017). Information security risk assessment in hospitals. The Open Medical Informatics Journal, 11(1), 37-43. http://dx.doi.org/10.2174/1874431101711010037

Božić, V. (2023). Business continuity management in hospital [Master’s thesis]. https://www.researchgate.net/publication/368652428_Business_Continuity_Management_in_hospital

Cichonski, P., Millar, T., Grance, T., & Scarfone, K. (2012). Nist Special Publication 800-61, Revision 2: Computer security incident handling guide. NIST, U.S. Department of Commerce.

Kuzminykh, I., Ghita, B., Sokolov, V., & Bakhshi, T. (2021). Information security risk assessment. Encyclopedia, 1(3), 602-617. http://dx.doi.org/10.3390/encyclopedia1030050

Pamungkas, E. D., Fatonah, N. S., Firmansyah, G., & Akbar, H. (2023). Disaster recovery plan analysis based on the NIST SP 800-34 framework (Case Study: P.T. Wijaya Karya (Persero) Tbk.). Jurnal Indonesia Sosial Sains, 4(09), 936-947.

Sasaki, H., Maruya, H., Abe, Y., Fujita, M., Furukawa, H., Fuda, M., Kamei, T., Yaegashi, N., Tominaga, T., & Egawa, S. (2020). A scoping review of hospital business continuity plans to validate the improvement after the 2011 Great East Japan earthquake and tsunami. The Tohoku Journal of Experimental Medicine, 251, 147-159. http://dx.doi.org/10.1620/tjem.251.147

U.S. Department of Health & Human Services. (2022). Healthcare system cybersecurity readiness & response considerations. https://files.asprtracie.hhs.gov/documents/aspr-tracie-healthcare-system-cybersercurity-readiness-

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Business Continuity Plan (BCP) – Phase 3

Part 1: Issue-Specific Security Policies

NIST SP 800-12 Rev 1 recommends three types of information security policies to help organizations create, maintain, and develop an effective information security program, reduce risks, comply with laws and regulations, assure operational continuity, and apply informational confidentiality, integrity, and availability. One type is issue-specific security policies (ISSP). For each of the following issues, use “SP 800-61 Rev. 2,” to create an ISSP document that includes the following:

For each policy, include an issue statement, a statement of the organization’s position, applicability, roles and responsibilities, compliance, points of contact, and supplementary information.

Establish reporting and communication channels for internal and external stakeholders.

Use of personal equipment on ABC Hospital’s network (BYOD)

Internet access

Personal use of company equipment

Removal of organizational equipment from your company’s property

Use of unofficial software

Design and development of an information security awareness and training program for an organization

Part 2: Legal Standard Operating Policies and Procedures 

A thorough legal standard operating policies and procedures (SOP) document is the foundation of a good business continuity plan. Standard operating procedures and policies provide the roadmap for management and staff to follow. These steps become the backbone of the business continuity plan, and they must govern every aspect of a company.

Using the Business Continuity Plan (BCP) – Phase 1 attached, design a 4-page manual presenting the legal standard operating policies and procedures, to describe incidents including, but not limited to, fire evacuation, ransomware attack, power outage, and pandemic situations.

Each policy or procedure must include information related to:

• Industry Compliance
• Business Operations
• Training and Awareness
• Disaster Recovery
• Incident Response

Part 3: Incident Response

Once an adverse event targeting a business is confirmed, it is labeled as an incident. That is the time to activate the incident response plan. After the plan is activated, procedures are followed for incident reaction. Most of the time, the incident is contained. Then, the end of all the problems begins and the organization makes a full recovery, with everything back to normal. This is incident recovery.

Use the guidelines provided by “SP 800-61 Rev. 2: The Computer Security Incident Handling Guide,” to design an incident response plan (IRP) for ABC Hospital. Include actions to be taken if each of the following adverse events occurs:

• Ransomware attack on one PC/user
• Power failure
• ISP failure

If a disaster renders the current business location unusable for a long time, and there is no alternate site to reestablish critical business functions, what would you suggest in a situation like this? Hint: Use the 7-step model recommended by NIST in SP 800-34r1 to develop and maintain a viable BC program for your company.

Support the BCP with a minimum of 4 scholarly resources.