SA-7.3 Contingency Plan: Emergency Mode Operation Plan
When critical systems fail or emergencies strike, your organization must continue protecting patient health information (ePHI) without interruption. HIPAA's SA-7.3 control requires you to establish and implement procedures that keep your essential business processes running securely even during crisis situations. This guide shows you how to build an emergency mode operation plan that satisfies HIPAA auditors and safeguards sensitive data when it matters most.
What this means
SA-7.3 requires healthcare organizations and their business associates to develop and maintain written procedures that enable the continuation of critical business operations while maintaining the security and integrity of ePHI during emergency situations. This includes defining which processes are critical, establishing alternative operational methods, and ensuring staff know how to execute these procedures when normal systems are unavailable or compromised. Emergency mode might involve paper-based workflows, manual verification processes, or failover systems that maintain PHI protection even under degraded conditions.
How to comply
- 1.Identify and document all business processes that handle or depend on ePHI and classify them by criticality to patient care and operations
- 2.Define specific emergency scenarios your organization could face (system outages, natural disasters, security incidents) and map procedures for each
- 3.Establish alternative operational procedures for each critical process, including manual backup workflows, data handling, and access controls during emergencies
- 4.Document role assignments and decision-making authority for emergency mode activation and escalation procedures
- 5.Create clear training materials and checklists staff can follow when emergency mode is activated, with minimal system dependencies
- 6.Test your emergency mode procedures at least annually, documenting results and any gaps discovered during testing
- 7.Maintain current contact lists, backup locations, and alternative technology resources needed to execute emergency procedures
- 8.Review and update your emergency mode operation plan whenever business processes, systems, or staffing significantly changes
Evidence auditors look for
- Written Emergency Mode Operation Plan document identifying critical business processes and alternative procedures
- Documented criticality assessment showing which ePHI-related processes must continue during emergencies
- Alternative workflow procedures for key functions (scheduling, billing, clinical documentation) with manual safeguards
- Staff training records and competency documentation for emergency mode procedures
- Annual testing logs showing emergency procedure drills, outcomes, and remediation of identified gaps
- Updated contact trees and resource lists (backup locations, equipment, alternate systems) with current information
- Incident response procedures that trigger and coordinate emergency mode activation across departments
- System failover documentation and manual backup procedures for critical ePHI systems
Frequently asked questions
When will FAQs be available?
The FAQ for this control is currently being prepared.
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