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Refined Scoring Levels

• 4–6 points: Level 1 – Initial
  IT is inconsistent and reactive, with minimal documentation. High risk to compliance, business operations, and patient care.
• 7–9 points: Level 2 – Defined
  Some practices and safeguards exist but are unevenly applied. Ongoing risk to business continuity and patient care delivery; limited readiness for audits.
• 10–12 points: Level 3 – Standardized
  Policies are documented and followed. Proactive compliance and risk management reduce exposure, but IT impact on strategic and clinical outcomes is limited.
• 13–17 points: Level 4 – Optimized
  IT governance supports compliance and business goals. Risks are actively managed, and service delivery is measured and improved, strengthening efficiency and patient experience.
• 18–20 points: Level 5 – Strategic
  IT is embedded in organizational strategy. It drives compliance assurance, innovation, and operational resilience, directly supporting patient outcomes and reducing organizational risk.

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Your Answers:

Point value for the answers from top to bottom is 1 through 5. Your answers are in blue.

IT Documentation - 0

Do you have the documentation to support audits, vendor reviews, and care continuity?

• No documentation; we rely on tribal knowledge.
• Some policies exist, but not consistently followed.
• Documentation is well-defined and accessible; useful for internal processes.
• Documentation is regularly maintained, reviewed, and supports compliance audits.
• Documentation is embedded into daily workflows and demonstrates compliance readiness at any time.

IT Governance - 0

Does governance ensure compliance and support patient-care goals?

• IT is reactive, addressing issues only when they arise.
• Goals are set occasionally, with little compliance oversight.
• Governance is formalized and monitored, but not fully tied to business/clinical goals.
• Governance ensures compliance, security, and operational effectiveness with measured outcomes.
• IT is fully integrated into clinical and organizational strategy, shaping patient outcomes and compliance posture.

IT Risk Awareness - 0

How do you protect ePHI and ensure compliance?

• Unaware of threats; rely on ad-hoc responses.
• Aware of risks, but no formal plan.
• Risk management policies exist, recognizing breaches are “when, not if.
• Regular assessments and updated controls against evolving threats.
• Continuous monitoring, rapid detection, containment, and recovery.

IT Culture - 0

Does your IT culture drive compliance and better outcomes?

• Reactive; firefighting with no formal guidance.
• Somewhat reactive, but service levels are defined.
• Proactive, preventing incidents before they affect care.
• Improvement-oriented and measured.
• Innovation-oriented and strategically aligned.

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