Gap Analysis: A Tool to Audit HIPAA Compliance


You’ve heard of the SWOT analysis – a technique used to help businesses identify their strengths, weaknesses, opportunities, and threats. The SWOT analysis helps an organization identify its priorities and set a course of action.

Similarly, a “gap” analysis can help a healthcare organization discover how well their current operations conform to a standard. From the gap analysis, you can see what actions your organization needs to take to meet the standard.

Gap Analysis

Healthcare organizations often use a gap analysis to see how well they’re complying with the Health Insurance Portability and Accountability Act (HIPAA). If they find that their operations fall short of the standards, they have identified a gap and can work towards fixing it.

Does HIPAA Require a Gap Analysis?

You won’t find “gap analysis” in the HIPAA rule. Like the SWOT analysis, the gap analysis is a business management technique used in all industries. When used in healthcare compliance, a gap analysis helps you measure your current procedures against the requirements found in the HIPAA privacy and security rules.

Gap Analysis Steps

A gap analysis for HIPAA compliance can be done in 4 steps:

  1. Identify your current operations. Are your policies and procedures up to date? Are employees following them?
  2. Compare your current operations with the standards. Do they meet all the requirements of the HIPAA privacy and security rules?
  3. Identify the gaps. Where does your HIPAA program fall short? Be specific and thorough.
  4. Develop a plan to make your current operations match the standards. This plan needs to be actionable and time bound. Assign implementation steps to the appropriate employees.

Use a Gap Analysis Tool

You can conduct a gap analysis the pen-and-paper way, or you can try a tool that will streamline the process for you. Our software uses a tool called “Self Assessment” that automatically calculates your risks (or gaps) based on the number of met vs. unmet HIPAA standards.

As you complete your compliance tasks in HIPAAtrek, the Self Assessment reads your progress and displays unmet standards as risks. Open the at-risk standards and click “Fix It” to assign the implementation task to employees.

An automated gap analysis takes the guesswork out of your HIPAA program so you know what you need to do to meet the standards. The action plan is already made for you.

Contact us today to learn more about the Self Assessment feature or other features of our HIPAA management software.

Being Prepared For Investigations

Are you prepared for a potential investigation?

Don’t wait until the Office of Civil Rights (OCR) comes knocking. Use this checklist to prepare now for potential investigations and find the confidence that comes from knowing you can prove compliance.

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