The core purpose of the policy review during the Readiness phase is gap analysis. It’s a foundational step to understand the current state versus the target state defined by the CSF controls. This gap analysis directly informs the remediation plan, which is critical for a successful assessment. The other options describe final deliverables, risk-based scoping (which happens earlier), or unrelated activities.

HITRUST assessments are evidence-based. A fundamental principle is that an organization must do what it says it does. The documented procedure (the ‘say’) defines the requirement. If the evidence (the ‘do’) does not align with that stated requirement, the control is Non-Compliant. The assessor’s judgment or the system owner’s opinion does not override this objective discrepancy.

In a HITRUST assessment, the organization seeking certification is always responsible for the controls protecting its information. Under the shared responsibility model, the organization must understand which controls are managed by the provider (e.g., physical security of the data center) and which are its own responsibility (e.g., configuration of its virtual machines, access management to its applications). The organization must provide evidence for the controls it is responsible for, which may include reviewing the provider’s compliance reports (like a SOC 2) as part of its own control implementation.

HITRUST assessments require testing for operational effectiveness. This means verifying that controls are not just in place (policy), configured (updated signatures), or believed to work (interview), but are actually functioning as intended to mitigate the identified risk. A practical test, such as a simulated malware attack via email that is successfully blocked, provides the most direct evidence that the control is effective in a real-world scenario.

HITRUST certification is based on the systems and controls in scope at the time of the assessment. A significant change, like a major platform migration, can invalidate the previous test results because the control environment has fundamentally changed. The organization has a responsibility to proactively engage with its assessor to perform a change analysis. The assessor will help determine if the change is ‘substantial’ (requiring interim testing) or not. Ignoring the change or waiting could lead to a certification that does not accurately reflect the current state.

Scoping factors like System Type directly feed into the HITRUST MyCSF tool to generate the appropriate set of control requirements (the baseline) and their required maturity levels. A system that handles regulated data (e.g., PHI, PCI) is inherently higher risk and will be assigned a more comprehensive baseline (e.g., a higher baseline) and higher maturity level targets (e.g., ‘Measured’ instead of ‘Implemented’) compared to a low-risk internal wiki. This is a core mechanism for tailoring the CSF to organizational risk.

A common failure in remediation is creating a ‘paper control’—a policy or procedure that exists only on paper. HITRUST requires controls to be fully implemented and operationally effective. Simply writing a document to close a gap from a past assessment will likely lead to a new finding in the next assessment for lack of implementation evidence. The organization must operationalize the procedure, train relevant staff, and begin generating a track record of evidence (logs, reports, tickets) that proves the control is functioning in practice.

The HITRUST Maturity Model is a key differentiator. It moves beyond a simple yes/no compliance check. It assesses the maturity of a control across five levels: Policy, Procedure, Implemented, Measured, and Managed. This allows an organization to demonstrate that a control is not only in place but is consistently applied, its effectiveness is monitored, and it is improved based on feedback. The required maturity level is determined by the risk-based scoping factors.

The primary official deliverable is the HITRUST Certification Report (often referred to as the Validated Report with a certification decision). This is a standardized report issued by HITRUST after rigorous quality assurance of the assessor’s work. It is the recognized artifact used to demonstrate certification status to customers, business partners, and regulators. The MyCSF tool is the working platform, and the assessor’s worksheets are supporting detail, but the Certification Report is the formal credential.

The core purpose of the policy review during the Readiness phase is gap analysis. It’s a foundational step to understand the current state versus the target state defined by the CSF controls. This gap analysis directly informs the remediation plan, which is critical for a successful assessment. The other options describe final deliverables, risk-based scoping (which happens earlier), or unrelated activities.0