Incident response and cyber resilience

The incident response and cyber resilience requirement means you must be able to prepare for, execute, and prove an incident response process that is tailored to healthcare operational impact (patient safety, clinical downtime, and care continuity) ¹. Operationalize it by defining healthcare-specific scenarios, running drills, and maintaining downtime communication procedures that work under real outage conditions ¹.

Key takeaways:

• Your plan must be healthcare-operations-first: patient care continuity, downtime workflows, and clear clinical communications ¹.
• Evidence matters as much as documents; run response drills and keep artifacts that prove execution ¹.
• Build cyber resilience into response: backups, alternate workflows, and decision rights for isolation vs. care delivery.

Compliance leaders in healthcare rarely fail an exam because they “don’t have a plan.” They fail because the plan is generic, untested, or disconnected from how the organization delivers care during outages. The incident response and cyber resilience requirement is explicit: prepare and execute incident response tailored to healthcare operational impact ¹. That tailoring is the difference between a policy binder and an operational capability.

This page translates the requirement into a practical implementation blueprint for a Compliance Officer, CCO, or GRC lead supporting IT, Security, Privacy, and clinical operations. You’ll get a step-by-step build plan, the evidence to retain for auditors and internal assurance, and the common failure modes (like drills that never touch EHR downtime procedures or call trees that assume email still works). You can implement this without waiting for a perfect enterprise program: start with defined triggers, roles, downtime communications, and recurring exercises that create audit-ready artifacts. Where tooling helps, Daydream can centralize evidence, control ownership, and exercise tracking so you can show maturity without rebuilding your GRC stack.

Regulatory text

Requirement (HICP-08): “Prepare and execute incident response tailored to healthcare operational impact.” ¹

Operator interpretation (what you must do):

• Prepare: Document and resource an incident response capability that accounts for healthcare realities: clinical system downtime, patient safety risks, regulated data exposure, and time-critical communications ¹.
• Execute: Demonstrate that the process is used in practice through drills and real incident records, not just written plans ¹.
• Tailored to operational impact: Your response must explicitly connect cyber actions (isolation, shutdowns, recovery) to care delivery decisions (divert, delay, manual workflow, downtime charting, communicating with clinicians and patients) ¹.

This is an incident response and cyber resilience requirement because it expects both response coordination and the ability to continue or safely restore operations under adverse conditions ¹.

Plain-English requirement summary

You need a working incident response program that is built for healthcare operations, can function during outages, and is proven through drills and retained records. A generic IR plan copied from another industry fails the “tailored to healthcare operational impact” test ¹.

Who it applies to (entity and operational context)

Entities: Healthcare organizations ¹.

Operational context where this becomes mandatory in practice:

• Organizations that rely on EHR/EMR, imaging, lab, pharmacy, scheduling, revenue cycle, identity systems, or connected clinical devices to deliver care.
• Environments with shared services and third parties that could drive incidents (cloud EHR hosting, managed security, billing, transcription, device manufacturers). Even though HICP is guidance, auditors and internal risk committees often expect alignment because it is healthcare-specific ¹.

What you actually need to do (step-by-step)

1) Define “healthcare operational impact” for your organization

Create a one-page impact map that translates cyber events into operational outcomes:

• Critical clinical services (ED, ICU, OR, inpatient, outpatient, home health).
• Critical systems and dependencies (EHR, AD, network, PACS, LIS, pharmacy).
• Safety and continuity thresholds (what must stay up, what can be deferred, what has a manual fallback). Output: Healthcare Impact & Downtime Map (owned by Security with Clinical Ops sign-off).

2) Establish incident categories and triggers tied to care delivery

Write clear criteria for escalating to an incident and who declares it. Include healthcare-specific triggers such as:

• EHR unavailable or integrity in doubt.
• Suspected ransomware or mass encryption.
• Compromise affecting regulated data repositories.
• Network segmentation events that disrupt clinical devices. Output: Incident Classification & Escalation SOP.

3) Build a role-based incident response structure that works during downtime

Assign named roles and alternates:

• Incident Commander (often Security/IT leader)
• Clinical Operations Lead (nursing/CMO delegate)
• Privacy/Compliance Lead
• Communications Lead
• Legal liaison (internal or outside counsel)
• Third-party coordination lead (for EHR host, MSP, device vendors) Define decision rights for “containment vs. care continuity” so teams do not improvise during a crisis. Output: IR RACI + Contact Tree, including non-email contact methods.

4) Write and validate downtime communication procedures

HICP’s recommended control explicitly calls for maintaining downtime communication procedures and running response drills ¹. Your communications must assume common failure modes (email down, single sign-on down, paging delays). Minimum scope:

• How clinicians are informed of downtime status and expected workflows.
• How leadership is briefed (situation report cadence and format).
• How third parties are engaged (pre-approved escalation paths). Output: Downtime Communications Playbook (with tested channels).

5) Create healthcare-specific playbooks (not just one IR plan)

Build short playbooks that align cyber actions to operational steps:

• Ransomware suspected
• EHR outage (availability) vs. EHR integrity concern (data trust)
• Data exfiltration suspicion
• Medical device network compromise affecting patient care areas Each playbook should include: detection signals, containment options, patient care impacts, downtime workflow activation steps, and recovery/validation steps. Output: Scenario Playbooks with clinical sign-off.

6) Prove execution through drills and after-action fixes

Run response drills and retain evidence ¹. Your drill must test:

• Decision-making with clinical leadership in the room.
• Downtime communications without relying on normal corporate tools.
• Transition from containment to recovery with operational priorities. Close the loop with corrective actions, owners, and due dates. Output: Exercise Plan, Attendance, Timeline, After-Action Report, Corrective Action Register.

7) Operationalize resilience: recovery objectives, backups, and validation

Cyber resilience in healthcare is more than backups; it includes restoring safe operations and validating data integrity before returning to normal workflows. Build procedures for:

• Prioritized restoration order aligned to patient care.
• Data integrity checks for clinical systems after incident containment.
• Known-good configuration baselines for critical systems. Output: Recovery & Restoration Runbooks and Post-Recovery Validation Checklist.

8) Centralize evidence and control ownership

To keep this audit-ready, store policies, playbooks, drill artifacts, and corrective actions in a system of record. In Daydream, teams commonly set this up as:

• Control owners (Security, IT Ops, Clinical Ops, Privacy)
• Recurring drill tasks with evidence upload requirements
• Corrective action tracking tied to each exercise This reduces the “we did it but can’t prove it” gap that drives findings ¹.

Required evidence and artifacts to retain

Keep artifacts that prove both preparation and execution:

Governance & design

• Approved incident response policy/standard (versioned)
• IR RACI and on-call roster with alternates
• Incident classification criteria and escalation SOP
• Healthcare Impact & Downtime Map with clinical approvals

Operational readiness

• Downtime communications playbook (channels, templates, call trees)
• Scenario playbooks (ransomware, EHR outage, integrity concerns)
• Third-party escalation list (EHR host, MSP, telecom, key device vendors)

Execution evidence

• Exercise schedule and materials
• Drill attendance records (include clinical leadership)
• After-action report with gaps, decisions, and lessons learned
• Corrective action register with closure evidence
• Incident tickets/records (for real events), including timelines and communications

Common exam/audit questions and hangups

Use these as a readiness checklist:

• “Show me the last drill. Who attended, what failed, and what changed afterward?” ¹
• “How does your incident response account for clinical downtime and patient care continuity?” ¹
• “If email is down, how do you notify clinicians and leadership?”
• “Who can authorize isolating a network segment if it affects ICU devices?”
• “Where is the evidence that downtime communication procedures were tested?” ¹

Frequent implementation mistakes (and how to avoid them)

1. Generic IR plan with no clinical integration
   Fix: Require clinical operations sign-off on downtime workflows and scenario playbooks.

2. Drills that test technical response but not communications
   Fix: Make communications a scored objective: message content, timing, and channel viability ¹.

3. No proof of execution
   Fix: Treat exercise artifacts as required deliverables, stored centrally with retention rules ¹.

4. No decision rights for “contain vs. continue care”
   Fix: Define and rehearse escalation paths and authority boundaries.

5. Corrective actions never close
   Fix: Track corrective actions like audit issues: owner, due date, evidence, closure review.

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this requirement, so focus on the practical risk: during a cyber event, healthcare organizations face patient safety exposure, operational disruption, and potential regulatory scrutiny if response is ad hoc or poorly documented ¹. The compliance risk usually shows up as:

• Inability to demonstrate an executed, healthcare-tailored incident response process.
• Lack of tested downtime communications and clinical coordination ¹.

Practical 30/60/90-day execution plan

Days 0–30: Establish the minimum viable, healthcare-tailored foundation

• Assign IR roles, alternates, and decision rights.
• Build the Healthcare Impact & Downtime Map with Clinical Ops.
• Draft downtime communications procedures (including “email down” fallback).
• Select 2 priority scenarios (common: ransomware, EHR outage) and draft playbooks.

Deliverables: IR RACI, escalation SOP, downtime comms playbook, 2 scenario playbooks ¹.

Days 31–60: Prove execution with a drill and close the biggest gaps

• Run a tabletop drill that includes Clinical Ops, Privacy/Compliance, IT, Security, and Communications.
• Document outcomes: timeline, decisions, what broke, what was unclear.
• Open corrective actions with owners and due dates; prioritize communications and clinical workflow gaps.

Deliverables: exercise artifacts + after-action report + corrective action register ¹.

Days 61–90: Operationalize resilience and harden recovery

• Convert top corrective actions into updated playbooks and procedures.
• Add recovery and validation runbooks for critical systems (restore order aligned to care delivery).
• Run a second drill that tests downtime communications under constrained conditions.
• Centralize evidence collection in Daydream (or your GRC system) with recurring tasks for drills and updates.

Deliverables: recovery runbooks, updated playbooks, second drill artifacts, evidence repository structure ¹.

Frequently Asked Questions

What qualifies as “tailored to healthcare operational impact” for this incident response and cyber resilience requirement?

Your incident response must explicitly address clinical downtime, patient care continuity, and healthcare-specific communications and decision-making ¹. Auditors look for clinical stakeholder involvement and playbooks that map cyber actions to care delivery impacts.

Do we need downtime communication procedures even if we have a general crisis communications plan?

Yes. HICP highlights maintaining downtime communication procedures as a recommended control, and healthcare outages often break normal channels ¹. Your procedure should work when email, SSO, or ticketing is unavailable.

What evidence is strongest to prove we “execute” incident response?

Drill artifacts (agenda, participants, injects, decisions), after-action reports, and corrective action closure evidence are the most exam-ready proof ¹. Real incident records also count if they show timelines, communications, and lessons learned.

How do we involve third parties without slowing response?

Pre-stage escalation paths and contract points of contact so response teams can engage third parties quickly during an incident. Keep a single “third-party escalation list” as part of the playbook package.

Who should own this requirement: Security, IT, Compliance, or Clinical Ops?

Security and IT usually run the technical response, but Compliance/Privacy and Clinical Ops must co-own the healthcare tailoring: downtime workflows, communications, and decision rights ¹. Assign explicit roles in your RACI and require joint participation in drills.

How can Daydream help without turning this into a tool project?

Use Daydream as the system of record for control ownership, drill scheduling, and evidence capture so you can prove preparation and execution with less manual coordination. Start by tracking the next drill and required artifacts, then expand to corrective actions and playbook versioning.

Related compliance topics

• 2025 SEC Marketing Rule Examination Focus Areas
• Access and identity controls
• Access Control (AC)
• Access control and identity discipline
• Access control lifecycle management

Footnotes

1. HHS 405(d) HICP, 2026