IT Governance and Compliance Policy¶

Policy Status: Active

This policy is currently active.

Purpose¶

To ensure Acme Corp's IT strategy aligns with business objectives, regulatory requirements, and industry standards while establishing clear governance structures and compliance monitoring processes.

Scope¶

This policy applies to all IT operations, activities, systems, and personnel at Acme Corp, including employees, contractors, and third-party service providers.

Policy Statement¶

IT Governance Structure¶

Governance Framework: - CTO provides executive oversight of IT governance and strategy - IT Steering Committee reviews major initiatives and investments - IT leadership defines standards, policies, and procedures - Regular reporting to executive team and board on IT performance

Roles and Responsibilities: - Define clear ownership for IT systems and services - Establish decision-making authority and escalation paths - Document approval processes for IT changes and expenditures - Maintain RACI matrix for IT functions

Strategic Alignment: - IT strategy reviewed and updated annually - Align technology investments with business objectives - Roadmap planning process for major initiatives - Regular stakeholder engagement to understand business needs

Compliance¶

Regulatory Compliance: - Maintain compliance with HIPAA, state data protection laws, and applicable regulations - GDPR compliance for any EU data subjects - Regular compliance assessments and gap analyses - Timely implementation of regulatory changes

Industry Standards: - Adhere to SOC 2 Type II requirements - Follow security frameworks (NIST, CIS Controls) - Implement industry best practices for healthcare technology - Maintain certifications relevant to business operations

Compliance Monitoring: - Quarterly internal compliance reviews - Annual third-party audits and assessments - Continuous monitoring of security controls - Remediation tracking for identified gaps

Performance Monitoring¶

Key Metrics: - System uptime and availability (target: 99.9%) - Incident response times and resolution rates - Security incidents and breach attempts - Backup success rates - User satisfaction scores - Cost per user/service metrics

Reporting: - Monthly IT performance dashboards - Quarterly business reviews with stakeholders - Annual IT performance report to executive leadership - Real-time alerting for critical incidents

Continuous Improvement: - Regular review of metrics and targets - Root cause analysis for incidents and outages - Technology refresh planning - Process optimization initiatives

Policy Review¶

Review Cycle: - All IT policies reviewed annually at minimum - Critical security policies reviewed semi-annually - Updates triggered by regulatory changes or incidents - Stakeholder input incorporated during reviews

Approval Process: - Policy changes reviewed by IT leadership - Significant changes approved by executive team - Compliance team validates regulatory alignment - Version control and change tracking maintained

Communication: - Policy updates communicated to all affected personnel - Training provided on significant policy changes - Policy acknowledgment tracked and documented - Accessible policy repository maintained

Roles and Responsibilities¶

Role	Responsibility
CTO	Ensure alignment with business goals, lead policy reviews, allocate IT resources
IT Leadership	Implement governance framework, monitor compliance, report on performance
Compliance Team	Monitor adherence to regulatory requirements, conduct audits, provide guidance
IT Steering Committee	Review major initiatives, approve significant investments, provide strategic direction
System Owners	Ensure systems meet compliance requirements, report on system performance
All IT Staff	Follow policies and procedures, report compliance concerns, participate in training

Procedures¶

1. Policy Development and Review¶

Annual review calendar established by January 1
Policy owners assigned for each policy
Reviews completed within designated month
Changes tracked in version control system
Approval obtained before publication

2. Compliance Assessment¶

Quarterly internal control testing
Annual risk assessment
Third-party audit coordination
Gap remediation planning and tracking
Documentation maintained for audit purposes

3. Performance Reporting¶

Automated metric collection where possible
Monthly dashboard generation
Trend analysis and variance reporting
Executive summary for leadership review
Action plans for underperforming areas

4. Governance Meetings¶

IT Steering Committee meets quarterly
IT Leadership meetings monthly
Ad-hoc meetings for urgent issues
Meeting minutes documented and distributed
Action items tracked to completion

Exceptions¶

Emergency situations may require expedited approval processes
Temporary non-compliance during remediation must be documented with timeline
Risk acceptance for specific controls requires executive approval
All exceptions documented in risk register
Exception reviews conducted quarterly

Compliance and Enforcement¶

Audit Rights: Internal audit and external auditors have full access to IT systems and documentation
Non-Compliance: Identified gaps must be remediated per agreed timeline
Regulatory Reporting: Breaches and compliance issues reported per regulatory requirements
Accountability: Policy violations subject to disciplinary action
Third-Party Oversight: Vendors must demonstrate compliance with relevant standards

References¶

HIPAA Security Rule (45 CFR Part 164, Subpart C)
HIPAA Privacy Rule (45 CFR Part 160 and Part 164, Subparts A and E)
SOC 2 Trust Service Criteria
NIST Cybersecurity Framework
ISO/IEC 27001 Information Security Management
COBIT 2019 Framework
GDPR (if applicable)

Revision History¶

Version	Date	Author	Changes
1.0	2025-11-08	CTO Office	Initial version migrated from Notion

Document Control - Classification: Internal/Confidential - Distribution: All IT staff, executive team, board of directors - Storage: GitHub repository - policy-repository