Business continuity and disaster recovery readiness

The business continuity and disaster recovery readiness requirement means you must keep documented, tested capabilities to sustain and restore critical operations after disruption, with evidence that the plans work. For HITRUST, auditors will expect clear scope, defined recovery objectives, exercised plans, and corrective actions tied to critical systems and third-party dependencies ¹.

Key takeaways:

• Scope BC/DR around “critical operations,” then map to systems, data, people, facilities, and third parties that enable them.
• Write plans that are executable (roles, runbooks, communications, backups), then test them and document results and remediation.
• Evidence wins audits: retain approvals, exercise artifacts, restore proofs, issue tracking, and change control showing plans stay current.

Compliance teams often treat BC/DR as a policy exercise and get surprised during assessment by a simple question: “Show me that you can recover your critical operations within your stated targets.” HITRUST-aligned readiness is less about perfect paperwork and more about proving operational capability with repeatable testing and traceable evidence ¹.

For a CCO or GRC lead, the fastest path is to (1) define what is “critical,” (2) set recovery expectations that match business risk, (3) document who does what during an outage, and (4) run exercises that produce audit-ready artifacts. The trap is over-scoping (trying to recover everything) or under-evidencing (running a test but not keeping the proof). Another common gap is ignoring third-party and cloud dependencies; your recovery posture is only as strong as the upstream services you rely on.

This page gives requirement-level implementation guidance you can hand to operations, security, IT, and business owners to execute quickly and pass scrutiny under the business continuity and disaster recovery readiness requirement ¹.

Requirement: Business continuity and disaster recovery readiness (HITRUST)

Operator goal: Maintain continuity and disaster recovery capabilities for critical operations, and be able to prove it with documented testing evidence ¹.

Plain-English interpretation

You need a living BC/DR program that answers four audit questions with evidence:

1. What must be kept running or restored first? (critical operations and supporting assets)
2. How will you keep it running or restore it? (documented plans, runbooks, backups, alternate processing)
3. Who is responsible and how do you coordinate? (roles, communications, escalation, decision authority)
4. How do you know it works? (exercises, restore tests, lessons learned, corrective actions)
   ¹

This is “readiness,” not “intent.” A plan that exists but is untested, unapproved, or outdated will fail the spirit of the requirement.

Regulatory text

Provided excerpt (licensed standard text not reproduced): “Baseline implementation-intent summary derived from publicly available framework overviews; licensed standard text is not reproduced in this record.”
Implementation-intent summary: “Maintain continuity and disaster recovery capabilities for critical operations.” ¹

What you, as the operator, must do:

• Identify critical operations and the systems/services that support them.
• Establish continuity and recovery strategies appropriate to the criticality.
• Document actionable plans and ensure responsible teams can execute them.
• Test continuity and recovery plans and retain documented evidence of tests and remediation ¹.

Who it applies to

Entities

• Healthcare organizations that process, store, transmit, or rely on sensitive health information and supporting systems.
• Service providers (including cloud/SaaS, MSPs, revenue cycle vendors, hosting providers, and other third parties) that support healthcare organizations and their operations ¹.

Operational context (what gets pulled into scope)

Expect BC/DR scope to include:

• Production applications and infrastructure supporting patient care, billing, scheduling, analytics, or other mission-critical functions.
• Identity systems, networks, security monitoring, and backup/restore tooling.
• Key third parties and upstream services required for operations (e.g., cloud hosting, EHR platforms, payment processors).
• Personnel dependencies (on-call rotations, privileged access, incident command) and facility constraints ¹.

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

Step 1: Define “critical operations” and the impact of downtime

1. Build a short list of business services (not systems): e.g., patient intake, clinical documentation, claims submission.
2. For each service, document:
   • Business owner
   • Peak operating periods
   • Operational, safety, legal, and financial impacts of disruption (qualitative is acceptable)
3. Produce a criticality tiering that drives recovery priority.
   Artifact: Business Impact Analysis (BIA) or equivalent “critical operations register.”

Examiner hangup: A “critical system list” without a business-service view. Tie systems to business services.

Step 2: Map dependencies end-to-end (systems, data, people, third parties)

For each critical operation:

• Systems/apps (primary and supporting)
• Data stores and interfaces (APIs, batch feeds)
• Identity and access dependencies (SSO, MFA, PAM)
• Required teams/roles
• Third parties and cloud services, including contact and escalation paths
  Artifact: Service dependency maps and a third-party dependency appendix to BC/DR.

Common failure: No documented third-party recovery commitments (your plan assumes a SaaS will be available). Add contractual and operational checks in Step 7.

Step 3: Set recovery objectives you can defend

Define, at minimum:

• RTO (how quickly you restore the service)
• RPO (how much data loss you can tolerate)
• MAO/MTD where relevant (maximum allowable outage/downtime tolerance)

Keep objectives consistent across BIA, system recovery runbooks, and third-party SLAs.
Artifacts: Recovery objectives matrix; approval record by business owners.

Audit hangup: Objectives exist, but no evidence they were approved by accountable business owners.

Step 4: Choose and document recovery strategies

Common strategies (mix as needed):

• High availability and failover for top-tier services
• Backups with verified restores for lower tiers
• Manual workarounds and alternate processing for short periods
• Alternate communications channels and decision structures

Document the strategy per service and confirm it aligns to RTO/RPO.
Artifacts: BC/DR strategy statement; architecture diagrams; backup architecture description.

Step 5: Write executable plans (not just policies)

Minimum plan set that tends to satisfy assessors:

• Business Continuity Plan (BCP): how the business operates during disruption (workarounds, staffing, prioritization).
• Disaster Recovery Plan (DRP): technical restoration steps by system (runbooks).
• Crisis/incident communications plan: internal escalation, customer notices, third-party notifications, regulator/customer triggers.
• Call trees / on-call procedures: names can be in a system link; keep the plan current.

Use checklists and “if/then” decision points. Make it runnable at 2 a.m.
Artifacts: Version-controlled plans, role assignments, and approval workflow.

Step 6: Test continuity and recovery plans and document evidence

HITRUST-aligned readiness expects testing with evidence that plans work ¹. Build an exercise program that includes:

• Tabletop exercises (decisioning, communications, coordination)
• Technical recovery tests (restore from backup, rebuild, failover where applicable)
• Lessons learned and corrective actions with owners and due dates

Minimum evidence set for each exercise:

• Exercise scope and objectives
• Participant list and roles
• Timeline of events and decisions
• Screenshots/logs showing restore actions and outcomes (where applicable)
• After-action report and remediation tickets

Common hangup: “We tested” with no artifacts, or artifacts that do not show results (only agendas).

Step 7: Close the third-party gap (contracts + operational checks)

For critical third parties:

1. Confirm their BC/DR commitments (RTO/RPO or availability commitments) in the contract, order form, or SLA.
2. Request and review their BC/DR test attestation or summary, if available.
3. Build a provider outage procedure: how you detect, escalate, and implement workarounds.
4. Maintain alternate contact methods and escalation paths.

Artifacts: Third-party due diligence record; contract clauses/SLA excerpts; supplier outage runbook.

Step 8: Keep it current with change management

Tie BC/DR updates to:

• Major releases, migrations, new third parties, and architectural changes
• Org changes (roles, contact points, leadership)
• Post-incident findings

Artifacts: Change tickets referencing BC/DR review; annual/periodic review attestations; version history.

Required evidence and artifacts to retain (audit-ready checklist)

Evidence category	What to retain	What auditors look for
Governance	BC/DR policy, roles/RACI, approvals	Ownership and accountability
Scope	BIA, critical operations list, tiering	Clear definition of “critical”
Objectives	RTO/RPO matrix, business sign-off	Consistency and justification
Plans	BCP, DRP runbooks, comms plan, call tree method	Executable, current, controlled
Testing	Exercise calendar, test scripts, restore logs, after-action reports	Proof it worked and what changed
Corrective actions	Tickets, RCA, closure evidence	Issues tracked to completion
Third-party	SLA/contract terms, due diligence, escalation runbooks	Dependency management
Maintenance	Review logs, change control links	Plans updated after change

Common exam/audit questions and hangups

• “Show the BIA and how it drives recovery priorities.”
  Hangup: BIA exists but is outdated or not tied to systems.
• “Demonstrate a recent restore test. Where is the evidence?”
  Hangup: No screenshots/logs, or no proof the restored data was usable.
• “Who can declare a disaster and trigger customer communications?”
  Hangup: Decision authority unclear; comms approvals not defined.
• “How do you manage third-party outages?”
  Hangup: No runbooks; contracts don’t reflect criticality.

Frequent implementation mistakes (and how to avoid them)

1. Writing a policy and calling it done.
   Fix: prioritize runbooks, restore proofs, and after-action remediation.
2. Over-scoping to every system.
   Fix: start with critical operations and tiering; expand only where risk demands it.
3. RTO/RPO that engineering can’t meet.
   Fix: validate objectives against real architectures and recovery methods before sign-off.
4. Testing that never exercises real recovery steps.
   Fix: add technical restore tests for key data and systems, not only tabletop discussions.
5. Ignoring identity and security tooling dependencies.
   Fix: include IAM, logging, and key management in DR runbooks. You may restore an app and still be unable to operate securely.
6. Third-party BC/DR treated as “their problem.”
   Fix: document dependencies, require commitments, and create a provider outage playbook.

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this requirement. Operationally, BC/DR gaps drive real outcomes: prolonged outages, data loss beyond tolerated thresholds, missed customer obligations, and delayed incident response. In assessments, lack of testing evidence is a common control failure mode because assessors cannot credit intent without proof ¹.

Practical 30/60/90-day execution plan

Days 1–30: Establish scope, ownership, and minimum viable documentation

• Assign BC/DR owners for business and IT, plus an executive sponsor.
• Build or refresh the critical operations register and a lightweight BIA.
• Map dependencies for top-tier operations, including third parties.
• Draft RTO/RPO targets and obtain business owner approvals.
• Inventory existing plans/runbooks; identify gaps.
• Set an exercise calendar and define what “evidence” must be captured ¹.

Days 31–60: Build executable runbooks and run the first exercises

• Write or refactor DR runbooks for top-tier systems (step-by-step restore).
• Establish communications templates and escalation paths.
• Implement or validate backup coverage and access to restore tooling.
• Conduct a tabletop exercise for a realistic scenario (e.g., cloud region outage, ransomware affecting a core app).
• Publish an after-action report and open remediation tickets with owners.

Days 61–90: Prove recoverability and close evidence gaps

• Run at least one technical recovery test that generates concrete restore evidence for critical data/systems.
• Validate third-party commitments and document supplier outage procedures.
• Close high-risk remediation items or document compensating controls and timelines.
• Tie BC/DR updates into change management so plans stay current.
• Assemble an audit binder: scope, objectives, plans, tests, after-action reports, ticket closures.

Where Daydream fits naturally: If you need to operationalize evidence collection across plan versions, test artifacts, and third-party dependencies, Daydream can act as the system of record for BC/DR control evidence, linking exercises and remediation tickets to the exact requirement language your assessor will test against ¹.

Frequently Asked Questions

Do we need separate BCP and DRP documents?

You need both business and technical recovery coverage. That can be separate documents or one integrated set, but auditors will expect clear business workarounds and detailed technical restore steps with testing evidence ¹.

What counts as “documented evidence” of a DR test?

Retain the test plan, participants, timestamps, logs or screenshots showing restore actions, outcomes against RTO/RPO targets, and an after-action report with tracked remediation. Meeting notes alone rarely show that recovery actually worked.

How do we scope “critical operations” without boiling the ocean?

Start with a business-service list and tier it based on impact. Map only the dependencies required to restore the highest tier first, then expand scope as you mature the program.

How should we address cloud/SaaS dependencies?

Treat them as third-party dependencies: document what you rely on, confirm BC/DR commitments contractually where possible, and write an outage playbook that covers detection, escalation, and workarounds.

Our RTO/RPO targets are aspirational. Is that a problem?

Yes, if targets are not achievable with your current architecture and runbooks. Either improve recovery capabilities to match targets or revise targets with business sign-off and document the rationale.

Who should approve BC/DR plans and recovery objectives?

The accountable business owner for each critical operation should approve RTO/RPO and continuity expectations. IT/security leadership should approve technical DR strategies and runbooks alignment.

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