Conduct a Hospital Cybersecurity Risk Assessment in 10 Steps

Hospitals today sit at the crossroads of life-saving care and high-stakes digital risk. As technology becomes increasingly important to patient treatment and hospital operations, cybercriminals have turned their attention to healthcare systems—making breaches and data theft disturbingly common. Cyber incidents don’t just disrupt workflows; they can compromise patient data, disrupt critical services, and damage institutional reputations.

For IT leaders, the growing threat landscape underscores a pressing need to assess vulnerabilities and strengthen defenses. Learn how to conduct a 10-step hospital cybersecurity risk assessment to better protect your patients, data, and operations.

Ongoing Cybersecurity Threats in Healthcare

How many times in the past year have headlines shared nightmare scenarios for healthcare workers and patients that have unfolded due to cyberattacks? From ransomware that locks clinicians out of critical systems to stolen medical data published online, these incidents reveal just how vulnerable healthcare infrastructure can be.

Here are just a few examples that kept us up at night:

• Cyberattack led to harrowing lapses at Ascension hospitals, clinicians say

• Stolen test data and NHS numbers published by hospital hackers

• Patients at Ascension hospital network given dangerous doses of narcotics after disastrous cyberattack

• FBI issues warning about record number of US hospital hacks that led to death of a nine-month-old baby

So, what can we learn from these situations? For IT leaders, conducting a comprehensive cybersecurity risk assessment is both a technical necessity and a patient safety imperative. This process helps healthcare organizations:

• Identify system vulnerabilities before attackers do.

• Implement effective safeguards to minimize risk and disruption.

• Ensure compliance with critical regulatory requirements.

Why Cybersecurity in Healthcare Is a Patient Safety Issue

Cybersecurity isn’t just an IT concern; it’s a core component of patient safety. When hospital systems go down because of ransomware or data breaches, clinicians can lose access to critical patient information, delaying diagnoses, treatments, or even emergency procedures. According to a 2023 Ponemon Institute study, 66% of healthcare organizations reported that cyberattacks disrupted patient care, with many linking incidents to poor patient outcomes and increased mortality rates.

Beyond operational risks, healthcare providers have a regulatory and ethical obligation under the Health Insurance Portability and Accountability Act (HIPAA) and other standards to protect patient data and ensure care continuity. A single breach doesn’t just expose sensitive records—it can jeopardize lives. By treating cybersecurity as a patient safety priority, healthcare leaders can:

• Strengthen trust.

• Maintain compliance.

• Safeguard both digital and physical well-being.

Step-by-Step Guide to Conducting a Cybersecurity Risk Assessment

Follow these 10 steps to perform a cybersecurity risk assessment tailored to the unique needs of the healthcare industry:

1. Establish Scope and Objectives

Begin by defining the scope of your risk assessment. Determine which systems, networks, and data you will evaluate. In a hospital setting, this often includes:

• Patient records.

• Medical devices.

• Administrative systems.

• Communication networks.

Clarify your objectives: Are you assessing compliance with HIPAA? Looking to improve overall security posture? Preparing for a potential cyber insurance audit? Establishing clear goals will guide the entire process and ensure you cover all necessary areas.

2. Assemble Your Assessment Team

A successful risk assessment requires input from a diverse team of stakeholders. Include IT staff, cybersecurity experts, compliance officers, and representatives from various departments such as administration, clinical services, and human services. This multidisciplinary approach ensures you consider all potential risks and their impact on different aspects of the hospital’s operations.

3. Identify and Classify Assets

List all assets within the scope of your assessment. This includes:

• Hardware: servers, workstations, medical devices.

• Software: electronic health records (EHR) systems, applications.

• Data: patient records, financial information.

Classify these assets based on their importance to hospital operations and the sensitivity of the data they handle. For instance, patient records and medical devices typically warrant higher priority due to their critical role in patient care and compliance requirements.

4. Identify Threats and Vulnerabilities

Next, identify potential cyber threats to your assets. Threats can include:

• Cyber-attacks: malware, ransomware, phishing.

• Insider Threats: disgruntled employees, human error.

• Physical Threats: theft, natural disasters.

Assess vulnerabilities in your systems that these threats could exploit. Common vulnerabilities in hospitals include outdated software, weak access controls, and unsecured medical devices. Tools like vulnerability scanners and threat intelligence reports can help you identify these weaknesses.

5. Assess the Impact and Likelihood of Risks

Evaluate the potential impact and likelihood of each identified threat, and consider the consequences of a successful attack or failure of a system. For example, a ransomware attack on an EHR system could halt hospital operations and put patient lives at risk. Assign a risk score based on the severity of the impact and the probability of occurrence. This scoring will help prioritize which cybersecurity risks need immediate attention and which ones you can address over time.

6. Develop a Risk Mitigation Plan

Based on your risk assessment, develop a plan to mitigate identified risks. Prioritize actions that address the highest risks first. Common mitigation strategies might include:

• Implementing Stronger Access Controls: Use multi-factor authentication and limit user permissions to reduce the risk of unauthorized access.

• Regular Software Updates and Patch Management: Keep systems and applications up to date to protect against known vulnerabilities.

• Encrypting Sensitive Data: Make sure to encrypt patient records and other critical data, both at rest and in transit.

• Conducting Employee Training: Educate staff on cybersecurity best practices and how to recognize phishing attempts and other social engineering attacks.

• Enhancing Network Security: Segment networks to limit the spread of malware and implement intrusion detection and prevention systems.

7. Monitor and Review Continuously

Cybersecurity is an ongoing process, not a one-time event. Be sure to:

• Continuously monitor your systems for new threats and vulnerabilities.

• Conduct regular security audits.

• Update your risk assessment periodically to reflect changes in the threat landscape and your hospital’s technology infrastructure.

You can use real-time monitoring tools to detect and respond to incidents promptly.

8. Document and Report Findings

Thorough documentation is crucial for transparency and accountability. Document all findings from your cyber risk assessment, including:

• Identified threats.

• Vulnerabilities.

• Risk scores.

• Mitigation actions.

Prepare a comprehensive report for hospital leadership and other stakeholders, detailing the current cybersecurity posture and steps being taken to improve it. This report can also serve as evidence of due diligence in meeting regulatory requirements and standards.

9. Engage Leadership and Allocate Resources

Effective cybersecurity requires support from hospital leadership. Present your findings and mitigation plan to the executive team, emphasizing the importance of cybersecurity in protecting patient safety and maintaining operational integrity. Advocate for necessary resources, such as:

• A budget for new security tools.

• Additional staff for the IT team.

• External expertise for specialized tasks like penetration testing.

10. Foster a Cybersecurity Culture

Finally, fostering a culture of cybersecurity within the hospital is essential for long-term success. Encourage all staff members to take an active role in protecting sensitive information and maintaining security best practices. Regularly update employees on new threats and provide ongoing training to ensure they remain vigilant and informed.

Frameworks and Regulations To Guide Healthcare Cybersecurity

To create a resilient cybersecurity strategy, healthcare organizations can rely on several well-established frameworks and regulations:

• NIST Cybersecurity Framework (CSF): A flexible framework designed to help organizations identify, protect, detect, respond to, and recover from cybersecurity threats. Widely used across industries, it supports risk-based decision-making.

• HIPAA: Establishes national standards for protecting patient health information and mandates administrative, physical, and technical safeguards to ensure data privacy and security.

• HITECH Act (Health Information Technology for Economic and Clinical Health): Expands HIPAA requirements, promoting the secure adoption of EHRs and strengthening breach notification rules.

• ISO/IEC 27001: An international standard that provides a systematic approach to managing sensitive information through an information security management system.

• HITRUST CSF: A certifiable framework that integrates elements from NIST, HIPAA, and ISO standards to help healthcare organizations achieve unified compliance and security management.

Aligning your risk assessment with these cyber frameworks and certifications not only strengthens protection against cyber threats but also ensures compliance during audits.

Building a Resilient, Patient-Safe Hospital Environment

Resilience in healthcare isn’t just about strong firewalls and secure servers; it’s about creating a culture where cybersecurity and patient safety go hand in hand. A solid cybersecurity foundation keeps hospital systems running smoothly, ensuring clinicians have the tools and data they need to deliver timely, effective care.

The insights gained from a risk assessment should feed directly into:

• IT governance.

• Incident response plans.

• Ongoing staff training.

Regular policy updates and testing help teams stay prepared as threats evolve, while adopting best practices builds long-term confidence and stability.

Just as important, resilience is about people as much as technology. When everyone—from nurses to network admins—understands their role in protecting data and supporting safe care, hospitals become stronger, more responsive, and better equipped to serve patients securely.

Securing Healthcare: Your Roadmap to a Stronger Cyber Defense

Conducting a comprehensive cybersecurity risk assessment is a critical step for IT leaders in healthcare. By systematically identifying, evaluating, and mitigating risks, you can protect your hospital’s networks, safeguard patient data, and ensure compliance with regulatory requirements. Remember, cybersecurity is a continuous effort, and staying proactive and informed is key to maintaining a secure healthcare environment long-term.

Looking for more training and resources on cybersecurity and other essential IT skills? Explore ACI Learning’s Online IT & Cybersecurity Courses, designed to equip healthcare IT professionals with the knowledge and tools they need to excel in their roles.