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Maintaining staff training policies in healthcare

Kapua Iao July 01, 2025

HIPAA Compliance

Maintaining staff training policies in healthcare

Organizations are susceptible to cyber threats that compromise systems and patient data. In fact, a main contributor to data breaches is human error, with at least 95% of breaches in 2024 attributed to individual mistakes. Failure to provide adequate staff training results in these breaches and leads to severe HIPAA penalties, among other issues.

HIPAA training equips employees with the tools they need to handle protected health information (PHI). Strong staff training policies help to safeguard organizations from employee-related breaches and encourage regulatory compliance. Such effective training policies can reduce an organization’s risk by teaching employees how to avoid certain activities by defining protocols for detecting, preventing, and remediating cyberattacks.

What HIPAA says about staff training

The Health Insurance Portability and Accountability Act (HIPAA) protects the confidentiality and security of PHI from theft and fraud. The legislation mandates that anyone who works with medical records should undergo HIPAA training to familiarize themselves with its requirements. Training educates staff on the specific requirements of the HIPAA rules, including the proper use, disclosure, and safeguarding of PHI.

Under the Privacy Rule, “a covered entity must train all members of its workforce on the policies and procedures with respect to [PHI] . . . as necessary and appropriate for the members of the workforce to carry out their functions within the covered entity." Furthermore, the HIPAA Security Rule adds that both covered entities and their business associates must “implement a security awareness and training program for all members of [their] workforce including management.”

Together, both rules require that healthcare organizations train employees on all PHI-related policies and procedures, including how to keep data safe during storage or transmission and how to report unsecured and secured PHI breaches. Having a policy to address the training of employees validates that significant topics are addressed and that staff understand what they need to do when working in the healthcare industry.

Developing a staff training policy

Developing a HIPAA compliant training policy verifies that all employees are aware of and adhere to the standards set by HIPAA. Here are some points to consider when developing a training policy:

Make HIPAA training a priority
Tailor the training program to staff roles and responsibilities
Use a variety of teaching methods
Keep open communication with staff and clarify when asked
Document training and evaluation through acknowledgment forms

Before creating a training program, organizations must familiarize themselves with HIPAA’s regulations and requirements. They will need to determine who needs to be trained (e.g., full-time or part-time employees, contractors, and other relevant personnel) on what part of HIPAA, based on their job functions, and when. Even more, all new hires should receive HIPAA training within a reasonable time after starting.

Training material and modules will need to be specific to each organization’s overall policies and procedures. Providers will need to decide if training should be in person, online, or a combination of both. A comprehensive staff training policy will also assess whether training should be annual to reinforce knowledge and/or as needed to provide small updates and changes.

HIPAA employee training topics

HIPAA training covers various topics to prevent breaches from occurring and to minimize the effects when they do occur. Topics might serve as an introduction to HIPAA or a refresher to long-term employees and might also provide in-depth knowledge for specific roles or situations.

Overview of HIPAA: the objectives of the act, who it applies to, what it applies to, and how it is enforced

HIPAA’s regulations: an overview of HIPAA’s rules, including the Privacy Rule, Security Rule, HITECH Act, Breach Notification Rule, Enforcement Rule, and the Omnibus Final Rule

HIPAA terminology: definitions of specific terms used in the legislation (e.g., PHI and the minimum necessary standard)

Patients’ rights: the rights that patients have regarding their PHI and how healthcare employees should communicate these rights

Disclosing PHI: how to properly disclose PHI, including to whom and when appropriate

Preventing HIPAA violations: the common types of HIPAA violations and best practices to avoid unnecessary disclosures

HIPAA violation consequences: the results of HIPAA violations, including reporting and mitigating the damage caused by violations

Being a HIPAA compliant employee: employees’ legal obligations to comply with HIPAA rules and the potential consequences of failing to do so

How does a staff training policy ensure HIPAA compliance?

The purpose of HIPAA training is to guarantee healthcare employees understand their HIPAA responsibilities while completing their work duties in HIPAA compliant ways. Therefore, a staff training policy would give all employees answers to questions about HIPAA compliance. Such a policy would equip employees with the knowledge and skills needed to handle PHI securely under the law.

A staff training policy highlights the importance of confidentiality, integrity, and availability of health information, and teaches employees to recognize and respond to physical and cyber threats. By keeping staff informed about regulatory updates and organizational procedures in a policy, regular training sessions maintain a culture of compliance and vigilance. Ultimately, a strong policy should reduce the risks of HIPAA violations and enhance the overall security culture of the organization.

Risks of not using a staff training policy in healthcare

HIPAA compliance demonstrates an organization’s dedication to safeguarding patient privacy and adhering to healthcare regulations. The absence of clear guidelines can lead to confusion and uncertainty about what constitutes appropriate use and disclosure of PHI. It can also result in inconsistent practices among healthcare providers, leading to misunderstandings and breaches of confidentiality.

Failure to train staff on HIPAA poses tangible risks to healthcare organizations, their employees, and their patients. Real risks include:

The heightened possibility of PHI being sent to the wrong person or part of a larger, unsecured breach
Misunderstandings about patient access and sharing permissions among staff
Further time spent fixing organizational inefficiencies, correcting mistakes, or reporting breached emails
An increase in staff stress and a decrease in job satisfaction

Unknowledgeable staff can result in misdiagnoses and other medical errors that lead to avoidable health complications, adverse incidents for patients, and HIPAA violations. HIPAA violations can also lead to reputational damage, legal consequences, and financial penalties. Healthcare organizations can reduce such issues and risks and maintain HIPAA compliance by implementing secure staff training policies for all employees.

Maintaining a staff training policy in healthcare

As imperative as it is to have and develop a staff training policy, it is also crucial to maintain it continuously. The policy (and the training itself) needs to be kept up to date with patients aware of possible problems before they occur. Organizations must periodically review and update their staff training policy so that it remains relevant and compliant with current laws and organizational practices.

There are several ways to monitor and maintain a healthcare staff training policy, including:

Retaining records of all training sessions, with information such as dates, participants, and content covered
Seeking feedback on training content, delivery, and relevance to staff roles
Conducting regular assessments to gauge comprehension and identify areas of improvement
Monitoring adherence with regular audits, spot checks, or incident reporting to authenticate the effectiveness of both the policy and the training

More info: What does HIPAA training look like in 2025

FAQs

Who is required to undergo HIPAA training?

HIPAA training is required for all members of a covered entity’s workforce, including employees, volunteers, trainees, and business associates who have access to PHI. This includes healthcare providers, administrators, IT staff, and anyone else who handles PHI.

Related:

How often should HIPAA training be updated for employees?

HIPAA training should ideally be updated annually to reflect any regulatory changes and address emerging security risks.

Who is responsible for overseeing HIPAA training?

The HIPAA Privacy and Security Officer is responsible for developing, implementing, and overseeing the HIPAA training program.

Are business associates also required to undergo HIPAA training?

Yes. Business associates who access PHI must also receive HIPAA training to ensure they understand how to protect patient information and comply with the law.

Learn about: Tips to spot phishing emails disguised as healthcare communication