Crosswalk pair
HIPAA and PIPEDA, control by control
15 canonical controls in Keel’s library satisfy clauses of both HIPAA and PIPEDA. Implement each once, attach the evidence once, and it counts toward each standard. The overlap is the work you don’t repeat.
The overlap
What the two libraries have in common
Every figure here counts canonical controls in Keel’s library, not clauses of either standard. Each standard’s own authored count is on its framework page.
15
Controls that satisfy both
Canonical controls that crosswalk to at least one clause of each.
31
In Keel’s library for HIPAA
48% of them also map to PIPEDA.
30
In Keel’s library for PIPEDA
50% of them also map to HIPAA.
72
Evidence artifacts expected
Across the shared controls, from Keel’s evidence guidance. Gathered once.
The mapping
Controls that satisfy both
Each row is one control in Keel’s library and the clauses it answers on each side. Do the work once; both columns are then evidenced by the same artifacts.
| Canonical control | HIPAA clauses | PIPEDA clauses |
|---|---|---|
| Governance & Risk | ||
| Grievance & complaint handling Anyone affected by the organization - a worker, a customer, a neighbor - has a reachable route to raise a concern or a complaint, including a complaint about how their personal data is handled; every complaint received is recorded together with what was decided and done about it; cases are resolved without undue cost or delay; and outcomes are tracked so recurring causes get fixed. The route is published where the people who might need it will actually see it, and it is reachable by somebody outside the organization who has no account, no contract and no internal contact. | 164.530(d)(2) | 4.10, 4.10.2, 4.10.3, 4.10.4 |
| Information security policy A board-approved policy set covering information security and the handling of personal data, sized to the scale of the organization and the type of activities it actually carries out, reviewed at least annually and communicated to the workforce. The policy set states the direction the organization is taking on information security - what it commits to, and what it requires of everyone doing work for it - so it sets where the program is going rather than only recording what it already does. One or more named individuals are designated to coordinate the program the policies describe - the person in charge of it, named rather than implied, with the designation recorded in writing, made known to the people who need it and kept current as roles change - so there is someone who answers for the policies being carried out and not only for their being published. How far the policies go, and how far the measures they require go, is judged against four things together: the organization’s size, complexity and capabilities; its technical infrastructure and the security capabilities of its hardware and software; what the measures cost; and how likely the risks they address are and how much damage they would do. A policy may be changed at any time, provided the change is documented and is actually put into effect rather than only written down. Review is triggered by events as well as by the calendar: the policy set is revisited and updated when the requirements the organization is under change, when the threat picture changes, when the technology it depends on changes, and when its mission changes - and it is enforced rather than only issued, with non-compliance handled through the stated route instead of tolerated. | 164.316(a), 164.530(i)(1) | 4.1.4, 4.7 |
| Named security & privacy officers One named individual is accountable for developing and implementing the organization’s security policies and procedures, and one for the policies and procedures governing personal data - the same person where the organization is small enough that saying so is honest. A named contact point receives questions and complaints about how personal data is handled. The same naming discipline runs down through the rest of the program: the responsibilities and authorities for the security duties the organization depends on are assigned by leadership to named roles - including who answers for the management system meeting its requirements and who reports on how it is performing to leadership - and each holder is told what they hold and what they may decide, as are the people who have to go to them. Every designation and assignment is recorded in writing, published where the people who need it will find it, kept current as roles change, and reviewed when the organization changes shape. The same discipline is applied to the security duties themselves rather than only to the senior posts: the organization works out which information security responsibilities exist across the whole of it - who owns each asset and each information-handling process, who decides on a risk, who administers each control, who reviews access, who handles an event - and allocates every one of them to a role sized to what the organization actually needs rather than to an org chart it copied. The allocation is checked for gaps and for conflicts, so no duty is left with a role that no longer exists and no single role holds two that should be held apart, and a duty is reallocated when its holder leaves rather than lapsing with them. | 164.308(a)(2), 164.530(a)(2) | 4.1, 4.1.1, 4.1.2, 6 |
| Access Control | ||
| Access control policy Rules for granting, reviewing, and revoking access to systems and data based on business need and least privilege; anyone who works with sensitive data, or in a place from which it can be reached, is individually authorized for that work or supervised while doing it; and a documented emergency route exists to obtain the data when the normal access path is unavailable, with every use of that route recorded and reviewed afterwards. The rules also settle the opposite question: which actions, if any, a person may take on a system without identifying or authenticating themselves at all. Those actions are identified rather than left as whatever the system happens to permit, they are limited to what the organization’s business actually requires, and each one is documented in the system’s security plan together with the reasoning that justifies it, so an unauthenticated path is a decision somebody made and can be asked about. The rules are enforced by access control lists set on the data itself, not only by what an application chooses to show: permissions on local and remote file systems, on databases and inside applications are configured to the holder’s need to know, so information a role has no business reading is unreachable rather than merely unadvertised. What an authorized user may DO is limited on the same terms as what they may read: the types of transaction and function each role is permitted to execute are decided in advance and enforced by the system, so holding access to an application does not carry the right to run every operation inside it, and an action outside the permitted set is refused rather than merely unadvertised in the interface. Enforcement is centralized wherever the systems support it - access decisions for enterprise assets are made by a single directory service or single sign-on provider rather than by each system keeping its own list - and the systems that make those decisions are themselves known: an inventory of the organization’s authentication and authorization systems is maintained, including those run by a service provider on its behalf, and reviewed on a defined cadence. | 164.308(a)(3)(ii)(A), 164.308(a)(4)(ii)(B), 164.312(a)(2)(ii) | 4.7.1, 4.7.3 |
| Data Protection & Privacy | ||
| Data classification & handling Information is classified and handled per its sensitivity, with rules for labeling and protection - including the everyday handling rules that stop it being seen, overheard or picked up by people with no business reading it, so exposure that happens incidentally alongside legitimate work is limited rather than accepted. The handling rules are written to cover disclosure that nobody intended as much as disclosure that somebody chose, they say what an unauthorized disclosure is against the organization’s own privacy and confidentiality rules rather than leaving that to judgment in the moment, and they reach every medium the information travels in - spoken, on paper, on a screen and in a system - because the incidental exposure they exist to limit does not respect the boundary between an administrative, a physical and a technical safeguard. Labeling is the procedure that makes the classification visible, and it is defined rather than left to habit: there is a label for each level of the scheme, a rule for how the label is applied in each form the information takes - a document, an email, a file, a database field, a screen, a report, a piece of removable media, a printed page - and, where a system supports it, the label is carried in metadata so it can be acted on automatically rather than only read. The person who creates or receives the information applies the label at that point rather than later, the label travels with the information when it is copied, extracted, exported or transferred so a copy does not arrive unclassified, and information derived from or aggregated out of classified sources is labeled for what the combination is worth rather than for what the least sensitive input was. Where a label would itself disclose something, an agreed alternative is used and recorded, and the procedure covers what to do when unlabeled information is found. On storage media the marking carries more than the level: it states the distribution limitations that apply and any handling caveats that travel with the contents, so somebody who picks the item up knows what they may do with it without having to ask. Where the organization exempts a class of media from marking because it never leaves a controlled area, that exemption is defined and recorded as a decision rather than practiced as an omission. Underneath the scheme sits a documented DATA MANAGEMENT PROCESS that the classification and the handling rules are derived from: it states how sensitivity is decided, who owns each category of data, how each category is handled, the retention limits that apply to it and what disposal it requires, and it is reviewed and updated on a defined cadence and whenever a change to the organization would alter it. That process is also what the DATA FLOWS are documented against - where each category of information originates, which systems and processes it moves between, and where it crosses out to a service provider - recorded as documentation somebody maintains rather than reconstructed when a question is asked, and reviewed on the same cadence. | 164.530(c)(2) | 4.3.4, 4.7.2 |
| Data retention & secure disposal Data is retained per policy and securely destroyed when no longer needed. Retention periods are set against the purpose the data was collected for and any legal or contractual obligation to keep it, recorded per category of data rather than left to whoever is looking at the record, and enforced when they run out - data goes because its period ended, not because somebody finally objected to keeping it. Destruction leaves it unrecoverable rather than merely removed from an index, and what was destroyed, when, by what method and on whose authority is recorded. The hardware and media that held it reach a defined final disposition at end of life, by a route the organization has decided in advance rather than by whatever happens to the box; and any media that stays in service is cleared of that data before it is reused, reassigned, or passed to anyone else. Disposal is not confined to data and media: the documentation, the tools and the system components the organization has defined as needing it are disposed of by techniques and methods it has approved in advance - so a decommissioned appliance, a retired build server, a set of network diagrams or a licensed utility leaves the organization by a route somebody chose, and the route is recorded on the same terms as a data destruction. A retention period has two ends and both are stated: the minimum the organization must keep the data for, and the maximum beyond which it may not be kept - so retention is bounded in the direction of keeping too long as well as of destroying too early. | 164.310(d)(2)(i), 164.310(d)(2)(ii) | 4.5, 4.5.2, 4.5.3, 4.7.5, 8(8) |
| Encryption in transit & at rest Strong cryptography protects sensitive data in transit over public networks and at rest in storage. The mechanisms are chosen to do two things and are judged against both: prevent unauthorized disclosure of the information, and prevent or detect unauthorized change to it - in transit, so a message altered between sender and receiver is caught rather than delivered, and at rest, so a stored record cannot be modified undetectably by somebody with access to the storage but not to the key. Which information is protected at rest, and on which system components, is decided and recorded rather than left to whatever the platform encrypts by default. The scope named explicitly reaches the end-user device as well as the server: data held on laptops, desktops and other end-user devices that carry sensitive information is encrypted at the device or volume level, so a device that leaves the building is an object somebody lost rather than a disclosure. And data in transit is encrypted wherever it is sensitive, not only where it crosses a public network - a session between two internal systems is protected on the same terms when what it carries warrants it. Where a law, a regulation or a contract requires the cryptography to be VALIDATED rather than merely strong, the organization uses a cryptographic module that carries the validation that instrument names, and it confirms that validation against the specific module, version and operating mode actually deployed rather than inferring it from the product’s name - because a validated module run outside the configuration it was validated in is not a validated module, and the certificate that proves the point is held as evidence rather than assumed to exist. | 164.312(a)(2)(iv), 164.312(e)(2)(ii) | 4.7, 4.7.1, 4.7.3 |
| Individual rights request handling Every request an individual makes about their own personal data - to see it or get a copy, to have it corrected or amended, to restrict how it is used or disclosed, or to be contacted only by a particular means or at a particular address - is logged when it arrives, the requester’s identity is checked, and the request is answered inside the window that right carries - 30 days for a request to see or copy, 60 days for a request to amend - with at most one 30-day extension, and only if the individual is told in writing why and by when. What is provided is what was asked for - INSPECTION, a copy, or both - in the form and format asked for where that is readily producible, arranging with the individual a convenient time and place to inspect or collect it, or mailing it where they ask; transmitted to a third party where the individual directs it in a signed writing naming that person and where to send it; and charged at no more than a reasonable cost-based fee. A refusal is given in writing in plain language with the reason; anything else that was asked for and is not refused is still provided; where the organization does not hold the data at all and knows who does, it tells the individual where to send the request instead of simply refusing; and the individual is told what to do next - review by a LICENSED HEALTH CARE PROFESSIONAL whom the organization designates and who took no part in the original decision, where that route exists, or the right to file a statement of disagreement with the record - and how to complain BOTH to the organization and to the Secretary of Health and Human Services, with the name or title and telephone number of the contact person or office to use. An accepted correction is made by identifying the records it affects and APPENDING the correction, or a link to where it lives, to them - the original entry stays and the record is added to, because a record that is silently overwritten loses the history a later reader needs and destroys the evidence of what was relied on at the time; the individual is told the correction was accepted and asked to identify, and agree to, the people it should be shared with, and those people are then notified along with anyone known to hold the data who may rely on it to the individual’s detriment; a correction notified to the organization by another organization is applied to its own copy the same way, by appending rather than replacing. Where a correction is refused, the individual may file a statement of disagreement; the organization may write a rebuttal and gives the individual a copy of it when it does; and the request, the refusal, the statement and any rebuttal are appended or linked to the record and travel with it - or an accurate summary does - on any later disclosure of the data they concern. An agreed restriction or an agreed alternative contact arrangement is recorded, and it ends only where the individual agrees to or asks for the ending IN WRITING, where they agree ORALLY AND THAT ORAL AGREEMENT IS WRITTEN DOWN, or by the organization telling the individual it is ending the agreement - and that last, one-sided route does not work AT ALL against a restriction the organization had no choice but to accept - the restriction on disclosing to a health plan an item or service the individual paid for in full out of pocket - and otherwise takes effect only for data created or received after the individual has been told; a request for alternative contact may be required in writing but never conditioned on the individual explaining why they are asking, and may otherwise be conditioned only on being told how any payment will be handled and on being given a workable alternative address or contact method. The organization records which sets of records these requests reach and which roles receive and process them, retains the request records for six years from creation or from when they last were in effect, whichever is later, penalizes nobody - inside or outside the organization - for making a request, complaining, or taking part in an investigation, and requires nobody to give up any of these rights as a condition of getting a service, a payment or a benefit. | 164.522(a)(2), 164.522(a)(3), 164.522(b)(2), 164.524(b), 164.524(c), 164.524(d), 164.524(e), 164.526(b), 164.526(c), 164.526(d), 164.526(e), 164.526(f), 164.530(g), 164.530(h) | 4.9, 4.9.2, 4.9.5, 4.9.6, 8(1), 8(2) |
| Privacy notice & transparency A privacy notice the organization owns, versions and dates, written in plain language and carrying the content it is required to carry: a prominent statement of what the notice is for, how personal data is used and disclosed with examples, what rights the individual has and how to exercise them, what the organization is obliged to do, a statement that the individual may complain both TO THE ORGANIZATION AND TO THE SECRETARY of Health and Human Services, with a brief description of how to complain to the organization and an assurance that nobody is retaliated against for doing so, the name or title and telephone number of a contact person or office, and the date it takes effect. It is available on request to anyone who asks, and it reaches the individual by the route their relationship with the organization sets: a health plan gives it at enrollment and tells those it covers where to get it at least once every three years; a provider treating people directly gives it no later than the first time it delivers a service - not before data is collected, which is a different and later trigger than a consent-first regime uses - or as soon as practicable after an emergency, and makes a good-faith effort to get a written acknowledgement of receipt, recording the attempt where none is obtained. Where the organization runs a website describing its services or benefits, the notice is posted prominently on it; where it has a physical site people come to, a copy is kept there for individuals to take away and the notice is posted in a clear and prominent place where someone waiting to be seen can read it. Where a notice is issued jointly with other organizations, each of them agrees to abide by its terms, and the notice describes with reasonable specificity both the organizations (or classes of organization) and the SERVICE DELIVERY SITES (or classes of site) it applies to, and says, where it is so, that those organizations WILL SHARE the individual’s data with each other to carry out the work the arrangement exists for - so a reader learns from the notice which premises they are covered at and that their data moves between the participants. Issue by any one participant discharges the duty for all of them. A copy of every version issued is retained, along with any acknowledgement of receipt and, where one could not be obtained, the record of the good-faith attempt. When a practice the notice describes changes, the notice is revised and made available before the change takes effect - not after it. | 164.520(b), 164.520(c), 164.520(d), 164.520(e), 164.530(i)(4) | 4.8, 4.8.1, 4.8.2, 4.8.3 |
| Record & accounting of disclosures A record is kept of the disclosures of an individual’s personal data made to other parties, each entry carrying the date, who received it and where they are if that is known, a short description of what was disclosed, and the purpose - or, where a written request prompted it, a copy of that request. On request, the individual is given an account of those disclosures covering the six years before the request, within 60 days and with at most one 30-day extension on written notice, and the first account asked for in any twelve-month period is provided without charge. A reasonable cost-based fee may be charged for a further account asked for by the same individual inside that twelve-month period only if the individual is TOLD THE FEE IN ADVANCE and is given the chance to WITHDRAW OR NARROW the request to avoid or reduce it - the fee is disclosed before the work is done, never billed after it. The organization records what an account has to contain, keeps a copy of each account it has provided, and records which roles receive and process these requests. | 164.528(b), 164.528(c), 164.528(d) | 4.9.1, 4.9.3 |
| Resilience & Continuity | ||
| Backups Regular, tested backups of critical data and systems with defined retention, each one a RETRIEVABLE EXACT COPY of the data it protects - complete and restorable, not a partial or lossy snapshot - including a copy taken before equipment holding that data is moved. Backup information is tested on a defined cadence to verify that the media are still reliable and the information still has its integrity - a restore actually performed, not a job that reported success - and it is protected by cryptographic mechanisms so a copy obtained by somebody who should not have it discloses nothing and cannot be altered undetected. Copies are held somewhere other than where the original lives: an alternate storage site is established, with the agreements needed to store backups there and to retrieve them when they are wanted, carrying security controls equivalent to those at the primary site rather than weaker ones because it is only a copy. The alternate site is chosen far enough from the primary that the same fire, flood, outage or regional event is unlikely to take both, and the organization identifies in advance the problems that would make the site hard to reach during a wide-area disruption - roads, transport, staff availability, network dependency - and states explicit mitigation actions for each rather than discovering them on the day. The recovery itself is a documented process and not only a schedule: it states which assets are in scope for recovery, the order in which they are brought back, and how the backup data is protected while it waits, and it is reviewed and updated on a defined cadence and whenever a change to the organization would alter it. Recovery data carries protection EQUIVALENT to the data it copies rather than weaker protection because it is a copy. And at least one instance of it is ISOLATED - held offline, off-site, or in a separately controlled service, out of reach of the credentials and the network paths that operate the live environment - so an event that reaches production does not also reach the copy that would undo it. Verification is performed at the point of USE as well as on the cadence: before a backup or any other restoration asset is relied on to bring a system back, its integrity is checked against the value recorded when it was taken and the check is logged - so a restoration does not carry corrupted or tampered data into a system that has just been cleaned. | 164.308(a)(7)(ii)(A), 164.310(d)(2)(iv) | 4.7.1 |
| Incident response A documented, tested plan to detect, triage, contain, remediate, and communicate security incidents, and to mitigate - so far as is practicable - the harmful effect of a use or disclosure of personal data the organization knows breached its own policies or the law. Each incident is recorded together with its outcome - what happened, what was done about it and how it ended - as a record of that incident, which is a different artifact from the plan being documented. The mitigation duty runs to violations by the organization itself AND to violations by the processors, vendors and other parties handling that data on its behalf: the plan reaches an incident somebody else caused with the organization’s data, so learning of one triggers the same containment and remediation as an incident inside its own walls rather than a request that the other party deal with it. Where an incident carries a duty to tell someone outside the organization, the plan discharges it on the clock the applicable law sets - and, where the organization has itself committed to a timeframe for telling people, on that commitment too, whether or not a statute stands behind it - rather than whenever the investigation happens to conclude: whether an incident is notifiable is decided against written criteria rather than argued after the fact, the regulator or supervisory authority is notified inside the deadline that regime states and inside any shorter or additional timeframe the organization has committed to, the people whose data is affected are told where the risk to them warrants it and, independently of that threshold, wherever the organization’s own privacy commitments say they will be told - so individual notification is never conditioned solely on a statutory risk test - and any other party that law or those commitments require to be notified is told on the same terms, and where a deadline is missed the notification itself explains the delay instead of passing over it. What a notification carries is fixed in advance rather than composed under pressure: to a regulator it describes at least the nature of what happened, including where possible the categories and the approximate number of people affected and of records involved; names a contact point - the data protection officer where there is one, otherwise whoever can answer - from whom more can be obtained; describes the likely consequences; and describes the measures taken or proposed to address it, including where appropriate the measures that will mitigate its adverse effects. Where all of that cannot honestly be given at once, it is given in phases without further undue delay rather than held back until the picture is complete, and each phase says what is still outstanding. The communication to the people affected describes what happened in clear and plain language and carries the same contact point, likely consequences and measures. Every compromise of personal data is documented whether or not it turned out to be notifiable - the facts of it, its effects, and the remedial action taken - in enough detail that a regulator reviewing the file can verify for itself that the notification decision was the right one. Recovery is part of the plan rather than something that follows it: service and data are restored to a state the organization has established is clean, the restoration is verified before the system is handed back to use, the cause is determined rather than inferred from the symptom, and the weakness the incident exposed is fixed - with the plan itself updated for what the incident showed about it. Between the report and the response sits an assessment step that is a duty of its own: every reported event is assessed against written categorization and prioritization criteria by people competent to apply them, and the decision - whether this event is an incident, and at what severity - is recorded with the reasoning, so two assessors reach the same answer and an event judged not to be an incident is a decision somebody made rather than a report that went quiet. Learning is treated as a duty separate from fixing the incident in front of you: the types, volumes and costs of incidents are quantified and reviewed as a set for what the pattern says, and what is learned is pushed back into the controls, the risk assessment, the awareness material and the assessment criteria themselves rather than staying in the report of the incident that produced it. The plan is a documented incident response policy with supporting procedures, issued to the roles it binds, owned by a named role, and reviewed and updated on a defined cadence. The people the plan assigns roles to are trained for them: within a defined period of taking the role, again when the system or the plan changes in a way that affects it, and on a defined cadence thereafter, with the content revised for what exercises and real incidents have shown. The capability is TESTED rather than assumed - on a defined cadence, using tests the organization has chosen for the purpose, such as a tabletop, a walkthrough, a simulation or a live exercise - and that testing is coordinated with the organizational elements that own the related plans, incident response and contingency planning in particular, so the two do not each assume the other. Handling and reporting are supported by automated mechanisms rather than run by hand at the worst moment: detection, triage, tracking, evidence collection and the routing of a report are automated so far as the organization’s systems allow, and the reports that must go outside are produced and sent by mechanism rather than composed under pressure. The roles the plan assigns are named across the functions an incident actually needs and not security alone - legal, IT, information security, facilities, communications, human resources, the responders and the analysts - and the assignment is reviewed on a defined cadence. So are the CHANNELS: a primary and a secondary mechanism for communicating and reporting during an incident are chosen in advance, on the understanding that the ordinary one may be the thing that is unavailable or compromised, and both are reviewed on the same cadence. The plan reaches the parties outside the organization that an incident actually involves: the suppliers and other third parties whose services, staff or systems would be part of the response are named in it, take part in the planning and the exercises, and are called on during response and recovery on terms agreed in advance rather than negotiated during the event. ESCALATION is a defined step and not a judgment call - the plan states the conditions under which an incident is escalated or elevated, whether by severity, by elapsed time, by the functions it has reached or by the obligations it triggers, who it goes to at each step, and what changes when it gets there. The analysis establishes what actually took place during the incident as well as why it happened, and the incident’s magnitude - how many systems, records and people it reached, and over what period - is estimated as the investigation proceeds and then VALIDATED against the evidence rather than left at the first number anybody said out loud. Notification runs to internal stakeholders as well as external ones, so the functions inside the organization that have to act on an incident are told on the same defined terms as the parties outside it. And containment is followed by ERADICATION as a separate act: the malicious code, the unauthorized access and the persistence left behind are removed and their removal is confirmed, so a contained incident is not mistaken for a finished one. | 164.308(a)(6)(ii), 164.530(f) | 10.1(1), 10.1(2), 10.1(3), 10.1(4), 10.1(5), 10.1(6), 10.2(1), 10.2(2), 10.3(1), 10.3(2) |
| Third-party Risk | ||
| Third-party / vendor risk management Due diligence, contractual safeguards, and ongoing monitoring of vendors that handle your data: the agreement obliges the vendor to comply in its own right with the security requirements that apply to it - an absolute standard, not a promise to match whatever you happen to do - to pass those obligations down to any subcontractor it brings in BY ENTERING INTO a contract or equivalent written arrangement with that subcontractor rather than by merely requiring equivalent practice of it, and to report to you, within a stated time, security incidents it becomes aware of and confirmed breaches of your data. Where a contract is not the instrument available, an equivalent written arrangement carrying the same obligations discharges the duty. The same obligations, together with the separation that keeps a related organization out of data it is not entitled to, are written into the governing document of any other arrangement that puts your data in the hands of a sponsor, parent, affiliate or plan. Diligence is not confined to security where the relationship warrants more: for suppliers significant enough to matter, the organization states the standards of conduct it expects of them - how they behave commercially and how they treat the environment around their operations - and screens candidates and incumbents against those stated expectations as part of the same selection and monitoring cycle, rather than accepting a signature on a code as evidence of it. Where the vendor handles personal data, the agreement binds it to privacy obligations no weaker than the commitments the organization has itself made about that data - the purposes it may be used for, the limits on passing it on further, and the help the organization needs in order to answer the requests individuals make about it - and the reporting duty above reaches a suspected as well as a confirmed compromise of that personal data, on the same stated clock. Which requirements apply to a given supplier is decided by the TYPE of relationship rather than by one clause set issued to everyone - what data it touches, what access it holds, whether it can affect the organization’s own service, and what it would cost if it failed - and the requirements are agreed and recorded before access begins rather than negotiated after go-live. Once the relationship is running, what the supplier actually delivers is reviewed against what was agreed on a stated cadence: the service records, the security reports and assurance the agreement entitles the organization to, the incidents it has declared, and the findings of any audit or test right the organization holds - exercised rather than merely retained. A change on the supplier’s side is managed as a change rather than discovered - a new subcontractor, a new location or jurisdiction, a change of ownership, a material change to the technology or to the people delivering the service is notified in advance under the agreement, assessed for what it does to the risk, and approved or refused before it takes effect. ACQUISITION is governed as its own act, under a documented system and services acquisition policy with supporting procedures, owned by a named role and reviewed on a defined cadence. When a system, a component or a service is bought, the contract states the security and privacy requirements it must meet - the functional requirements, meaning what the controls have to do; the strength requirements; the assurance requirements, meaning what evidence the supplier must produce that they work; the documentation the supplier must deliver and how it must be protected and distributed; the description of the development environment and of the environment the product will run in; and the acceptance criteria the delivery is measured against - all stated in the solicitation before a supplier is chosen rather than negotiated after award, and all expressed in terms of the applicable laws and standards. The supplier is required to describe the functional properties of the controls it will implement, and to provide design and implementation information for those controls at a level of detail the organization has specified, so the organization can judge them rather than take their existence on trust. It is also required to identify the functions, ports, protocols and other services the delivered product intends to use in the organization’s environment - and, for an external service provider, the ones its service requires - so an integration does not open a path nobody asked for. The program has three artifacts of its own. An INVENTORY of service providers lists every one the organization knows of, records the classification given to it and names the person inside the organization who owns the relationship, and is reviewed on a defined cadence and whenever a change to the organization would alter it. A POLICY governs the whole cycle - how providers are classified, how the inventory is kept, how they are assessed, how they are monitored and how they are decommissioned - owned by a named role and reviewed on the same terms. And a CLASSIFICATION is applied to each provider against stated criteria such as the sensitivity and volume of the data it holds, the availability the organization depends on it for, the regulation that reaches it, and the risk that remains after the controls in place - reviewed rather than assigned once. DECOMMISSIONING is performed rather than allowed to lapse: when a relationship ends, the user and service accounts are deactivated, the data flows into and out of the provider are terminated, and the organization’s data held in the provider’s systems is disposed of and the disposal evidenced. Who does what is settled before the relationship starts and written down on both sides: the cybersecurity roles and responsibilities of the organization, of the supplier, and of the customers and partners the arrangement reaches are established, communicated to each of them and coordinated between them, so a duty is not left in the gap where each party assumed the other held it. Planning and due diligence come before the agreement rather than after it - what the relationship would expose, what the candidate’s security actually looks like, and what would have to be true before it starts are established while declining is still an option. The risk a supplier carries is then held as a record rather than as an impression: understood, written down, prioritized against the other suppliers, assessed on a stated cadence, responded to with an owner and a date, and monitored for the whole life of the relationship instead of at onboarding only. The provider inventory records the SERVICES each one actually provides as well as its name, so what the organization has placed outside itself is answerable from the list. Where a PROCESS itself is provided from outside, it stays inside the management system’s control rather than leaving it: the controls the organization intends to apply to the external provider and the controls it intends to apply to the resulting output are defined separately and both are applied, because a well-governed supplier can still ship a nonconforming output. What the arrangement could do to the organization’s own ability to consistently meet its customers’ requirements is considered when those controls are set, and the verification or other activity necessary to establish that what arrives meets requirements is determined in advance and carried out rather than inferred from the supplier’s own assurances. | 164.308(b)(3), 164.314(a)(2), 164.314(b)(2) | 4.1.3 |
| People & Culture | ||
| Security awareness training Ongoing security and data-handling awareness training for all personnel, with completion tracking, and periodic security updates - reminders, bulletins and alerts - issued to the workforce between training cycles. New joiners are trained within a defined period of starting, anyone whose work is affected is retrained within a defined period after a material change to the policies or procedures, and every completion is recorded. The program itself rests on a documented awareness and training policy with supporting procedures, issued to the people and roles it binds, owned by a named role, and reviewed and updated on a defined cadence rather than at whatever point somebody notices it is stale. The curriculum names two threats explicitly, because both are answered by a person rather than by a system. The first is INSIDER THREAT: what the potential indicators look like - unexplained access outside a role, bulk copying, hostility after a disciplinary or a passed-over promotion, working around a control rather than raising it - and where to report a concern about a colleague, without the reporter being asked to conclude anything. The second is SOCIAL ENGINEERING AND SOCIAL MINING: the phishing message, the pretext phone call, the urgent request from an apparent executive, the person following somebody through a door, and the slower pattern of harmless-seeming questions that assembles into an answer nobody would have given at once - together with the instruction to report both the attempts that worked and those that did not. The curriculum is stated as a set of topics rather than left to whoever assembles the material. AUTHENTICATION: how multi-factor authentication works and why it is required, what makes a passphrase strong, and how credentials are stored and never shared. DATA HANDLING: how to identify sensitive information and how to store, transfer, archive and destroy it, together with the clear screen and clear desk habits that go with it - locking a screen on standing up, clearing a whiteboard at the end of a meeting, and putting paper and portable media away rather than leaving them out. UNINTENTIONAL EXPOSURE: the ways data leaves by accident, such as a message sent to the wrong recipient, a portable device left behind, or a file published to a wider audience than intended. INCIDENTS: how to recognize that something may be an incident and how to report it without first establishing that it is. MISSING UPDATES: how to tell that an asset is not receiving its security updates, and to report a failure of an automated patching tool rather than assume somebody is watching it. INSECURE NETWORKS: the risk of connecting to and sending organizational data over networks the organization does not control, including what is expected of a home network where people work from one. And beyond the common curriculum, ROLE-SPECIFIC training is given where a role carries specific risk - system administration, secure development, and the roles most likely to be targeted directly. | 164.308(a)(5)(ii)(A), 164.530(b)(2) | 4.1.4, 4.7.4 |
| Physical & Environmental | ||
| Physical security Physical access to facilities and equipment holding sensitive data is restricted and monitored, and a person’s access is validated against the role or function that justifies it rather than only logged; visitors are controlled as a case of their own, and so is access to software programs held for testing and revision. The facility and the equipment in it are safeguarded against tampering and theft as well as against unauthorized entry, and so is the SUPPORT INFRASTRUCTURE the systems depend on - the power feed and its distribution, the cabling and patching, the cooling and environmental plant, the fire detection and suppression, and the points at which communications enter the building - which is protected and monitored on the same terms rather than treated as building services somebody else owns, because a system is stopped as surely by reaching its power or its cooling as by reaching its data. The people who have to reach the site and the equipment when a continuity or recovery plan is invoked can still get in, by a route that is planned rather than improvised; and repairs and modifications to the physical security components of a facility - doors, locks, walls, and the hardware that controls entry - are recorded. The offices, rooms and facilities themselves are designed and fitted for that job rather than simply occupied: rooms holding sensitive information or the equipment that processes it are sited away from public access and from routes people pass through for other reasons, the building’s signage, directories and public information do not advertise where sensitive processing happens, doors, windows, walls and any shared boundary with another tenant are specified against the risk the room actually carries, and a room is locked and checked when it is unoccupied rather than left secured by whoever was last out. Monitoring is continuous rather than periodic: the premises are watched for unauthorized physical access by detection suited to the site - intruder alarms, cameras, contact and motion detection, staffed reception or patrols - covering every way in including delivery and fire doors and including the hours nobody is there, with an alarm going to somebody who responds and a stated response. The monitoring system is protected in its own right, so its configuration, its coverage and its recordings cannot be altered or read by the people it is watching, and recordings are retained and handled under the privacy rules that apply to them. The detection is specified rather than generic: intrusion alarms and surveillance equipment are employed as the means of monitoring physical access, and what they cover, what raises an alarm and who responds is decided in advance. Visitors are escorted for the whole time they are inside a controlled area and their activity while there is monitored, rather than being signed in at a desk and then left to move around; that applies to contractors, delivery and service personnel and auditors alike, and where somebody is authorized to work unaccompanied that is a recorded decision rather than a courtesy. Visitors leave a record: who came, who they were visiting, when they arrived and left, and the identification presented; the record is retained for a defined period, reviewed on a defined cadence rather than only after an incident, and anomalies in it are reported to a designated role. Deliveries and removals are controlled as a class - system components and equipment entering or leaving the facility are authorized before they move, the movement is monitored, and a record of what came in and what went out is kept - and the delivery area itself is arranged so that a delivery does not become unescorted access to the interior. PHYSICAL ACCESS IS LOGGED and not only permitted: entry to the facility and to each controlled area inside it is recorded - who entered, which area, and when - by the entry system, the staffed reception, the visitor register or a combination of them, and the log is retained for a defined period and reviewed on a defined cadence, so a person can be placed in a room at a time and matched against what the systems in it recorded. PHYSICAL ACCESS DEVICES are managed as a controlled inventory rather than handed out: the keys, locks, combinations, badges, cards, fobs and biometric enrollments that open a door are listed with the holder of each, issue and return are recorded against that person, the inventory is reconciled on a defined cadence, and combinations are changed and locks re-keyed when a device is lost or stolen, when a holder leaves or moves, and on the cadence the organization has set rather than only after an incident. All of this rests on a documented physical and environmental protection policy with supporting procedures, issued to the roles it binds, owned by a named role and reviewed on a defined cadence. | 164.310(a)(2)(i), 164.310(a)(2)(ii), 164.310(a)(2)(iii), 164.310(a)(2)(iv) | 4.7.3 |
Beyond the pair
Where else this work counts
A framework is lit when a shared control above also maps to it. Unlit means none of them do — an absence, not a judgment about that standard.
Also reached by these 15 controls
- AI Governance Essentials not reached
- Amazon Appstore Child-Directed Apps not reached
- Apple App Store Kids Category not reached
- CIS Critical Security Controls also reached
- COPPA also reached
- ESG Essentials also reached
- EU AI Act not reached
- GDPR also reached
- Google Play Families not reached
- ISO 9001 also reached
- ISO/IEC 27001 also reached
- ISO/IEC 42001 not reached
- NIST AI Risk Management Framework not reached
- NIST Cybersecurity Framework also reached
- NIST SP 800-171 also reached
- NIST SP 800-53 also reached
- PCI DSS also reached
- SOC 2 also reached
- SOX (Sarbanes-Oxley) Section 404 also reached
- US Employment Law - Federal Baseline also reached
The thesis
Why this is one project, not two
On a crosswalk-native model, PIPEDA mostly lights up controls you already built for HIPAA. You’re not re-uploading the same screenshot for a second audit. You apply the framework and see the genuine delta worth working. That’s the whole idea behind collect once, comply everywhere.
Next step
Add PIPEDA to the work you already did
Apply both frameworks in one workspace and see the overlap measured against the controls you already hold.