Incident response and resilience

The HITRUST incident response and resilience requirement expects you to operate two capabilities: (1) incident management that detects, contains, eradicates, and learns from security events, and (2) continuity practices that keep critical services running through disruption. To operationalize it quickly, define ownership, publish playbooks, test them, and retain evidence that proves the program runs.

Key takeaways:

• Build one integrated program that covers both incident response and business continuity/disaster recovery (BC/DR), with clear roles and escalation.
• Evidence beats intent: tabletop exercises, after-action reports, tickets, and recovery test results must be retained and traceable to systems in scope.
• Assessors look for practiced execution (playbooks + exercises), not just policies.

For HITRUST-scoped environments, “incident response and resilience” is less about writing a policy and more about running an operational muscle that works under stress. You need repeatable incident handling (triage through lessons learned) and continuity capabilities (backup/recovery, downtime procedures, and restoration testing) that match the criticality of the services you operate. If you process, store, or transmit sensitive healthcare data, or you provide services to organizations that do, your customers and assessors will expect you to show that interruptions and security incidents are managed in a controlled way.

This requirement is commonly failed on evidence and realism. Teams often have an incident response plan that no one has exercised, or they run a tabletop that never maps back to actual systems and owners. On the resilience side, organizations confuse “we back up data” with “we can recover a defined service within an agreed time,” and cannot produce test results that show recovery performance.

This page translates the incident response and resilience requirement into an execution checklist a CCO/GRC lead can run: roles, playbooks, exercises, integration with third parties, and the artifacts you will need when an assessor asks, “prove it.”

Regulatory text

Provided excerpt (framework overview summary): “Baseline implementation-intent summary derived from publicly available framework overviews; licensed standard text is not reproduced in this record.” ¹

Operator interpretation of the requirement: You must operate incident management and continuity capabilities that are active, owned, tested, and evidenced for the systems and services in your HITRUST scope. “Operate” means the process runs in real life: alerts are triaged, incidents are documented, post-incident actions are tracked to closure, and continuity plans are exercised with measurable outcomes ¹.

Plain-English interpretation (what the assessor is looking for)

Assessors generally want to see:

• Defined process: documented incident response (IR) and continuity/BC/DR procedures.
• Clear roles: named owners, on-call coverage, and escalation paths (including executives and legal/privacy).
• Repeatable playbooks: common scenarios, decision points, communications, and containment steps.
• Practice: exercises that simulate realistic events and produce improvements.
• Resilience outcomes: evidence you can restore systems/services and operate during disruption, not just that you have backups.
• Scope alignment: artifacts map to in-scope applications, infrastructure, and data flows ¹.

Who it applies to

Entity types (typical HITRUST profiles):

• Healthcare organizations handling regulated or sensitive data in operational systems (EHR adjunct tools, patient portals, claims platforms, analytics environments).
• Service providers that host, process, secure, transmit, or support healthcare customer data (cloud/SaaS, managed services, billing vendors, call centers, IT outsourcers) ¹.

Operational contexts where this requirement bites hardest

• 24/7 patient-facing services and clinical operations.
• SaaS environments with shared responsibility (your controls + cloud provider controls).
• Organizations with many third parties (incident notification and continuity dependencies).
• Distributed teams with no formal on-call, or no centralized ticketing/workflow for incidents.

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

Use this as a build-and-run sequence. Keep each step tied to in-scope systems.

1) Set governance: ownership, scope, and authority

1. Name an Incident Response Owner (security) and a Resilience Owner (BC/DR, IT operations). If you can only name one, define deputies.
2. Define “incident” and severity levels aligned to your business (security incidents, privacy incidents, availability incidents).
3. Document an escalation and decision matrix: who can declare an incident, who approves customer notification, who authorizes taking systems offline.
4. Map in-scope systems and dependencies: applications, databases, cloud accounts, endpoints, identity provider, logging, backup systems, critical third parties.

Deliverable: Incident Response & Resilience RACI + in-scope system inventory mapping.

2) Publish incident response playbooks that match real threats

Create playbooks that your team can run without improvising structure:

• Ransomware/extortion
• Phishing leading to account compromise
• Lost/stolen device (if endpoints are in scope)
• Cloud misconfiguration exposure
• Third-party incident impacting your service
• Availability incident (DDoS, major outage, corrupted deployment)

Each playbook should include:

• Trigger conditions (what signals start the playbook)
• First-hour checklist (triage, containment, evidence preservation)
• Evidence to collect (logs, snapshots, email headers, IAM events)
• Communications (internal, customer, regulators if applicable, third parties)
• Eradication and recovery steps, including when to use backups
• Closure criteria and lessons learned workflow

Practical tip: Write playbooks in the same system your team uses to work (ticketing/wiki/runbook tool), then link them from the IR plan. Static PDFs are hard to keep current.

3) Stand up an incident management workflow (tickets, timelines, and approvals)

1. Create an incident ticket type with required fields: detection source, severity, impacted systems, containment actions, root cause, customer impact, third-party involvement, and links to evidence.
2. Require a timestamped incident timeline for material incidents.
3. Define approval gates: e.g., comms approval by Legal/Privacy and executive incident commander for high severity.
4. Track corrective actions from post-incident reviews to closure, with owners and due dates.

Deliverable: Incident ticket template + sample completed incident records.

4) Build resilience: define recovery objectives and test against them

Resilience evidence needs to show you can restore service and protect data integrity.

1. Classify critical services (what must be recovered first and what can wait).
2. Document recovery objectives (RTO/RPO) for critical services as internal targets that leadership agrees to.
3. Document backup and restore procedures: where backups live, access controls, encryption, retention, and restore steps.
4. Run recovery tests: restore from backup, validate integrity, and demonstrate service restoration for in-scope systems.
5. Document downtime/continuity procedures for customer support, clinical operations interfaces (if applicable), and internal operations during outages.

Deliverable: BC/DR plan + backup/restore runbooks + recovery test reports.

5) Exercise the program and capture after-action improvements

You need two kinds of practice:

• Incident tabletop exercises (scenario-based decision and coordination practice)
• Technical recovery exercises (restore, failover, or rebuild steps tested)

For each exercise:

1. Define scenario, scope, and objectives tied to real systems.
2. Run the exercise with the actual responders (Security, IT Ops, Legal/Privacy, Comms, Customer Success, and key third parties where possible).
3. Produce an After-Action Report (AAR) with what happened, what failed, and action items.
4. Track action items to closure in your ticketing system.

Recommended control alignment: “Run incident playbooks and continuity exercises.” ¹

6) Integrate third parties into response and continuity

Most real incidents involve a third party (cloud provider outage, SaaS compromise, MSP mistake).

1. Contractually require incident notification and cooperation (who to contact, how fast, what details).
2. Add third-party contact paths into your on-call and escalation list.
3. Model third-party dependencies in your continuity plan (what happens if that provider is down).
4. Retain third-party incident reports and map them to your incident tickets when they affect you.

Operator reality: If you cannot show how a cloud/SaaS incident becomes your internal incident workflow, assessors may treat your program as “paper only.”

Required evidence and artifacts to retain

Keep artifacts in a controlled repository with versioning. Tie each artifact to scope.

Core governance

• Incident Response Plan (current, approved)
• Business Continuity / Disaster Recovery Plan (current, approved)
• RACI, on-call roster, escalation tree, communications plan
• System/service inventory with criticality and dependencies

Operational records (the highest-value evidence)

• Completed incident tickets (sanitized where needed)
• Incident timelines and decision logs for high severity events
• Post-incident review notes and After-Action Reports
• Corrective action tracking to closure (tickets, change records)
• Recovery test plans, results, and validation evidence (screenshots, logs, sign-offs)
• Tabletop exercise agendas, attendance, scenarios, and outcomes

Technical proof

• Logging/monitoring coverage notes for in-scope systems (what logs exist, where they go)
• Backup configuration evidence for in-scope systems (policy screenshots, job logs)
• Restore procedure runbooks and last test date evidence

Common exam/audit questions and hangups

Expect questions like these, and prepare the artifact path in advance:

1. “Show me an incident record from the last period.”
   Hangup: No formal incident tickets; only Slack threads.

2. “Which systems are covered by your IR/BC plans?”
   Hangup: Plans are generic and do not list in-scope applications or cloud accounts.

3. “How do you know you can restore production?”
   Hangup: Backups exist, but no restore tests or no evidence of successful restore.

4. “Who decides to notify customers and when?”
   Hangup: No written decision authority; inconsistent comms across incidents.

5. “How do third parties participate?”
   Hangup: Contracts lack notification obligations; contacts are outdated; no record of coordinating during an event.

Frequent implementation mistakes (and how to avoid them)

Mistake	Why it fails	Fix
One IR policy, no playbooks	Responders improvise; evidence is thin	Create scenario playbooks tied to in-scope systems and roles
Exercises happen but produce no action closure	Assessors see activity without improvement	Write AARs and track actions to closure in tickets
Backups treated as resilience	Recovery is unproven	Perform restores and document results for key services
No linkage between third-party incidents and your workflow	You cannot show operational control	Require notification in contracts and open internal incident tickets when impacted
Evidence scattered across tools	Audit becomes slow and inconsistent	Create an evidence index (artifact list + owners + locations)

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this requirement, so this page does not list specific cases. Operationally, weak incident response and resilience increases the likelihood of prolonged outages, uncontrolled data exposure, missed contractual notice obligations, and audit failure risk for HITRUST-scoped customers ¹.

Practical 30/60/90-day execution plan

This plan assumes you need audit-ready progress quickly. Adjust based on current maturity.

Day 0–30: Stand up the minimum operable program

• Assign IR and BC/DR owners; publish RACI and escalation tree.
• Confirm in-scope systems and critical third parties; publish a one-page dependency map.
• Publish IR plan and at least a small set of scenario playbooks aligned to your top risks.
• Implement incident ticketing workflow and required fields.
• Inventory backups for in-scope systems; document restore steps for critical services.
• Create an evidence index (what artifacts exist, where stored, owner, last updated).

Day 31–60: Prove it works with exercises and real records

• Run an incident tabletop using one playbook; produce an AAR and action tickets.
• Run a technical recovery test for at least one critical service; retain logs and sign-offs.
• Add third-party notification paths into on-call and incident communications.
• Tighten communications approvals (Legal/Privacy/customer comms) for higher-severity incidents.

Day 61–90: Expand coverage and harden evidence

• Add remaining playbooks (including third-party failure scenario and availability incident).
• Run a second exercise that crosses teams (Security + IT Ops + Comms + Customer Success).
• Demonstrate closure of at least some corrective actions from prior AARs.
• Build a “HITRUST-ready” evidence package export: last exercises, last recovery tests, sample incidents, and current plans.

Where Daydream fits naturally: Daydream can act as your control-to-evidence system of record, so playbooks, exercises, incident records, and recovery test artifacts stay mapped to the incident response and resilience requirement without last-minute audit scrambles.

Frequently Asked Questions

Do we need both incident response and business continuity/disaster recovery, or is one enough?

You need both capabilities operating: incident handling for security events and resilience/continuity for keeping or restoring services. Many incidents require both containment and recovery, so assessors expect them to connect.

What counts as acceptable “evidence” for this requirement?

Evidence is anything that proves the process ran: incident tickets, timelines, AARs, recovery test results, and action-item closure. Policies help, but assessors typically prioritize operational records.

We haven’t had a “real” incident. How do we show compliance?

Run tabletop exercises and technical recovery tests and retain the outputs. Exercises create the same kind of artifacts as real events: timelines, decisions, gaps, and corrective actions.

How do we scope incident response and resilience for a shared-responsibility cloud environment?

Document which layers you own (identity, configuration, logging, backups, application controls) and how you coordinate with the cloud provider during incidents. Keep evidence that your part of the workflow runs and that provider dependencies are documented.

How should third-party incidents be handled in our process?

Treat third-party-caused impacts as your incidents when your service or data is affected. Open an internal incident ticket, attach the third party’s notice/report, document your customer communications decisions, and track remediation.

What’s the fastest way to get ready for a HITRUST assessment on this requirement?

Publish the RACI and escalation tree, implement the incident ticket template, run one tabletop and one recovery test, and compile an evidence index that maps artifacts to in-scope systems. That set usually answers most first-round assessor questions.

Related compliance topics

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

Footnotes

1. HITRUST certification overview