Policy and standards governance

The policy and standards governance requirement means you must run a repeatable, auditable process for owning, approving, maintaining, and granting exceptions to security and privacy policies so they stay aligned to your assurance objectives under HITRUST. Operationalize it by assigning accountable owners, setting a review/approval cadence, controlling versions, and documenting exceptions with risk acceptance.

Key takeaways:

• Governance is a process, not a document: ownership, approvals, change control, and exceptions must be provable.
• Auditors will test operational evidence (minutes, approval records, version history, exception logs), not policy prose.
• The fastest path to compliance is a policy inventory + RACI + review cadence + exception workflow that maps to HITRUST assurance objectives.

“Policy and standards governance requirement” work fails for one predictable reason: teams focus on writing or refreshing policy documents and ignore the operating system that makes those policies real. HITRUST assessors generally want to see that your security and privacy policies are governed in a way that is controlled, consistent, approved by the right people, and kept aligned to the assurance objectives you are being measured against ¹.

If you are a CCO, GRC lead, or Compliance Officer, treat this requirement as a management control. Your goal is to show that policies and supporting standards are: (1) owned, (2) reviewed on a defined cadence, (3) approved through a defined authority path, (4) version-controlled, (5) communicated, and (6) allowed to deviate only via a documented exception process with risk acceptance. That governance layer is what creates auditability.

This page gives you requirement-level implementation guidance: who must be involved, the minimum steps to stand up the governance process quickly, what evidence to retain, where audits get stuck, and a practical 30/60/90-day plan you can execute with normal staffing.

Requirement: Policy and standards governance (HITRUST)

Plain-English interpretation
You must maintain governance for security and privacy policies aligned to assurance objectives. In practice, that means you can demonstrate a controlled lifecycle for policies and standards: create, approve, publish, review/update, and manage exceptions, with clear accountability and evidence at each step ¹.

What “good” looks like in an assessment
An assessor can pick any policy (for example, Access Control or Incident Response) and you can immediately show:

• Who owns it and who approved it
• When it was last reviewed and when the next review is due
• What changed (version history)
• How staff can find the current version
• How exceptions are requested, approved, time-bounded, and tracked to closure
  ¹

Who it applies to

Entity scope

• Healthcare organizations pursuing HITRUST certification
• Service providers that handle healthcare data, provide healthcare technology, or support regulated healthcare operations and want HITRUST certification alignment
  ¹

Operational context This requirement applies wherever your organization maintains security and privacy policies, including:

• Corporate security and privacy program documentation
• IT operations and infrastructure standards (configuration, logging, patching)
• Product and engineering standards (secure SDLC, change management)
• Third-party risk requirements that flow down via policy (security requirements for third parties)

If you have multiple legal entities, multiple product lines, or a shared services model, you need to define whether governance is centralized (one policy set) or federated (common baseline + BU addenda). Either can pass. The failure mode is informal “everyone has their own policies” with no approval trail.

Regulatory text

Provided excerpt (summary-level, licensed text not reproduced):
“Baseline implementation-intent summary derived from publicly available framework overviews; licensed standard text is not reproduced in this record.” The implementation intent is: Maintain governance for security and privacy policies aligned to assurance objectives ¹.

What the operator must do with this text
Convert “maintain governance” into a measurable process:

1. Define policy governance roles and decision rights (who writes, who reviews, who approves).
2. Define a review cadence and triggers for off-cycle review (major incidents, regulatory change, material system change).
3. Implement document control (versioning, effective dates, approvals, repository).
4. Implement an exception process with documented risk acceptance and expiration.
5. Keep evidence that the process runs as designed ¹.

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

Step 1: Build a policy and standards inventory (your control “system of record”)

Create a simple register that lists, at minimum:

• Policy/standard name
• Type (policy vs. standard vs. procedure)
• Owner (accountable), backup owner
• Approver(s) (authority)
• Current version, effective date, next review date
• Repository location (where the authoritative copy lives)
• Related assurance objective(s) (map to HITRUST scope) This inventory becomes the spine of governance. Without it, you cannot prove completeness.

Step 2: Assign ownership and approval authority (RACI that matches reality)

Define roles that exist in your org, such as:

• Policy owner (Accountable): usually Security, Privacy, or IT control owner
• Reviewers (Consulted): Legal, HR, Engineering, Operations, Compliance
• Approver (Accountable for approval): CISO for security, Privacy Officer for privacy, or a governance committee with documented charter
• Publisher (Responsible): GRC team or document control function
  Make sure approvals are not “email from someone who left.” Tie approvals to roles, not personalities.

Step 3: Set a review and update cadence, plus off-cycle triggers

Write the cadence into your governance standard (not just “as needed”). Common triggers you should document:

• Material changes to systems or business model
• Significant incidents or control failures
• Scope changes for HITRUST assessment
• New contractual commitments that require policy changes (for example, customer security addenda) You do not need complex bureaucracy. You do need predictable, provable review behavior.

Step 4: Implement document control (versioning + change history + access)

Minimum document control that auditors expect to see:

• Unique document IDs or consistent naming convention
• Version number, effective date, last review date
• Approval record (workflow, e-signature, ticket, or minutes with approval)
• Change log (what changed, why, who approved)
• Controlled repository (GRC tool, QMS, SharePoint with permissions, or similar)
• Published “current” vs. archived prior versions
  This is where many programs fail: policies exist, but nobody can prove which version was in force at a given time.

Step 5: Stand up an exceptions process (the governance “pressure valve”)

Policies will be violated in practice. Governance requires a controlled way to allow deviation:

• Exception request intake (ticket/form)
• Required fields: policy/standard section, business justification, compensating controls, risk statement, owner, requested duration, systems in scope
• Approval: security/privacy risk acceptance authority (document who can accept what)
• Conditions: compensating controls, monitoring requirements, and an expiration date
• Tracking: open exceptions list, periodic review, closure evidence
  Exceptions are often the strongest proof that governance is real because they show how you handle nonconformance.

Step 6: Prove alignment to assurance objectives (don’t overcomplicate)

You are not expected to paste HITRUST control language into every policy. You are expected to show that your policy set covers the assurance objectives in scope and is governed accordingly ¹. Practical options:

• A mapping tab in your policy inventory
• A “control-to-policy” crosswalk for the assessment scope
• A statement in each policy header/footer that lists the relevant domains/objectives

Step 7: Operationalize communications and attestation (as needed for your environment)

If your organization uses policy attestation:

• Define who must attest (all workforce vs. specific functions)
• Track completion evidence (LMS report, HRIS attestation record)
• Include third parties where contractually required (for example, contractors with network access)

If you do not run attestations, document the alternative: onboarding training, intranet publication, and periodic reminders tied to major policy updates.

Required evidence and artifacts to retain (audit-ready)

Keep artifacts that prove the governance process ran, not just that documents exist:

Core governance

• Policy governance standard/procedure (describes lifecycle, roles, cadence, exceptions)
• Policy committee charter and meeting minutes (if you use a committee)
• RACI for policy ownership and approvals

Document control

• Policy and standards inventory/register
• Current policies and standards with version history and effective dates
• Approval evidence (workflow logs, signed approvals, tickets, or minutes)

Review cadence evidence

• Review schedule
• Completed review records (what was reviewed, outcome, changes made, approver)

Exceptions

• Exception request log
• Approved exceptions with risk acceptance and expiration
• Evidence of compensating controls and closure

Alignment evidence

• Crosswalk showing policies/standards map to assurance objectives in scope ¹

Common exam/audit questions and hangups

Assessors and internal auditors tend to probe the same points:

1. “Show me how you know this is the current policy.”
   Hangup: multiple versions in email/PDF folders. Fix with a single authoritative repository and archival rules.

2. “Who approved this policy, and do they have authority?”
   Hangup: approvals by individuals without documented authority. Fix with a role-based approval matrix and committee charter.

3. “How do you ensure policies stay up to date?”
   Hangup: “we review annually” stated but no review evidence. Fix with a review calendar and completed review tickets.

4. “What happens when the business can’t comply?”
   Hangup: exceptions handled informally in Slack. Fix with a structured exception workflow and a standing exception review.

5. “How does privacy governance integrate with security governance?”
   Hangup: privacy policies exist but are not governed through the same lifecycle. Fix by extending the same governance mechanics to privacy documents.

Frequent implementation mistakes (and how to avoid them)

• Mistake: Treating policies as a one-time writing project.
  Avoid by measuring governance health: percent of policies reviewed on time, number of open exceptions, and overdue reviews (use internal metrics, not external stats).

• Mistake: No defined “standard” layer beneath policy.
  Avoid by separating “what” (policy) from “how” (standards/procedures). Auditors like seeing standards because they connect policy to operational control.

• Mistake: Approval theater.
  Avoid by documenting decision rights. A CISO approval means little if HR policies conflict and HR never reviewed them.

• Mistake: Exceptions with no expiration or closure.
  Avoid by requiring expiration and periodic review. If you cannot remediate quickly, extend with a new approval and updated risk statement.

• Mistake: Distributed policy sprawl across business units and tools.
  Avoid with a single inventory and a single place to find “current” documents, even if authorship is distributed.

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this requirement. Practically, weak policy and standards governance increases the chance that operational teams follow outdated guidance, apply inconsistent control baselines, and accept risk informally. For HITRUST, the immediate risk is an evidence gap: you may have “reasonable” policies, but fail certification expectations because you cannot prove governance operation ¹.

Practical 30/60/90-day execution plan

First 30 days: Establish control ownership and get to a complete inventory

• Name an executive sponsor (CISO, Privacy Officer, or equivalent) and a program owner in GRC.
• Build the policy/standards inventory and identify missing documents.
• Define the approval authority path (single approver or committee) and document it.
• Choose the system of record for policies and enable version control.
• Draft the exception workflow and required fields; start logging new exceptions immediately.

Days 31–60: Implement lifecycle mechanics and generate evidence

• Run a first-cycle review for the highest-risk policies (access control, incident response, data handling, third-party security).
• Capture approvals in a consistent format (ticket workflow, e-signature, or minutes).
• Publish “current” versions to the authoritative repository and archive prior versions.
• Stand up a policy review calendar and assign next review dates in the inventory.
• Start a weekly or biweekly exception triage (new, expiring, overdue).

Days 61–90: Align to assurance objectives and harden for assessment

• Create a crosswalk from assurance objectives in scope to policies/standards ¹.
• Backfill evidence for reviews and approvals that already happened but are not documented.
• Validate that privacy policies follow the same lifecycle as security policies.
• Run an internal mock audit: pick a policy at random and test whether you can produce end-to-end evidence in one sitting.
• If you manage many third parties, add policy flow-down checks to third-party onboarding or contract templates.

Where Daydream fits naturally
If you are juggling policy inventory, review workflows, approvals, and exception tracking across spreadsheets and shared drives, Daydream can centralize the policy system of record, automate review reminders, and keep approval and exception evidence attached to the exact document version auditors request. That reduces the scramble factor during a HITRUST assessment without changing your operating model.

Frequently Asked Questions

Do we need a formal policy committee to meet the policy and standards governance requirement?

No. You need documented decision rights and evidence of approvals and reviews. A committee helps in complex orgs, but a defined approver role with recorded approvals can also work ¹.

What’s the minimum evidence an assessor will accept for policy approvals?

Provide a consistent approval record tied to a specific document version and effective date (workflow log, signed approval, or meeting minutes). The key is traceability from approval to the published “current” policy.

How do we handle policies owned by different departments (Security, Privacy, HR, IT)?

Use one inventory and one governance procedure, even if ownership is distributed. Define who must review cross-functional policies so you don’t end up with conflicting requirements.

Can we store policies in SharePoint, or do we need a GRC tool?

SharePoint can work if it supports controlled access, version history, and a reliable way to show approvals. If those controls are weak in practice, a GRC platform can reduce evidence gaps.

How strict should the exceptions process be?

Strict enough that every deviation has an owner, a risk acceptance decision, compensating controls, and an expiration. If exceptions are easy to create but hard to close, your risk posture drifts and your evidence becomes hard to defend.

What does “aligned to assurance objectives” mean operationally?

It means your policy set covers the objectives in your HITRUST scope and you can show that mapping. Keep the mapping lightweight: an inventory column or a crosswalk is usually sufficient ¹.

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. HITRUST certification overview