An HIS self-evaluation answers, for each domain of the Quality Assurance Framework, how the service is doing, how it knows, and what it needs to do better, backed by outcomes and evidence. It ends with three priorities for the next 12 months, each with an action plan, and is submitted on the HIS portal when HIS asks.
What HIS asks for
HIS writes to registered services from time to time to ask for a self-evaluation, through its eForms portal, by a stated deadline. It is based on the Quality Assurance Framework and asks what you do well, what could improve and how you will make it happen. HIS expects honest answers and a quality improvement plan behind them.1
The self-evaluation should tell a story about where the service is against each key focus area, how you know, and where you could improve. HIS asks you to focus on outcomes, such as audit results, tests of change and lessons learned, and on their impact on patients and staff.2 The published tool is for reference only. The real one is completed on the portal.3
The 7 domains, and HIS's own questions
| Domain | HIS's key question | Evidence HIS suggests |
|---|---|---|
| 1 Clear vision and purpose | How clear is our vision and purpose? | Strategic plan, aims and objectives, key performance indicators, values |
| 2 Leadership and culture | How supportive is our leadership and culture? | Workforce planning, training matrix, staff survey results, governance structure, minutes |
| 3 Co-design, co-production | How well do we engage our stakeholders? | Patient information, participation policy, feedback and what changed because of it |
| 4 Quality improvement | How well do we manage performance? | Key policies, the medicines governance audit tool, training plan |
| 5 Planning for quality | How well do we improve performance? | Risk register, business continuity plan, quality improvement plan |
| 6 Relationships and 7 Quality control | What difference have we made and what have we learned? | Improvements in outcomes, feedback that led to change, audits, lessons learned, benchmarking |
Every service completes domains 1, 3, 4, 5, 6 and 7. Domain 2 is completed only if the service employs staff, including people working under practising privileges.2 Under the 7 domains sit 34 quality indicators, from Defined purpose and vision to Lessons learned and plans to apply.4
- Read the framework first. HIS says to understand the Quality Assurance Framework before you start. Read the quality indicators listed under each domain as well as the domain titles.
- Involve the right people. Patients, staff and partners, in proportion to the size of the service. A single-handed practitioner may do it alone.
- Say how you are doing. One short narrative per domain, written from the patient's experience, with an example of an improvement and its effect.
- Show how you know. Name the evidence. A number from an audit, a theme from feedback, a change after a complaint.
- Say what you will do better. Be specific and honest. HIS asks providers to be open and honest in their response.
- Upload only what helps. Leave out published national guidance, public documents, anything sent before and unchanged, anything that identifies a patient, and care notes, which inspectors sample on site.
- End on three priorities. The three things you will do better or differently over the next 12 months, each with an action plan that feeds your quality improvement work.
- Domain ______ HIS's key question ______
- How we are doing, in three sentences ______
- How we know, the evidence and its date ______
- An improvement we made and what it changed for patients ______
- What we need to do better or differently ______
- Evidence uploaded, file names ______
Weak and strong answers
| Weak | Strong |
|---|---|
| We value patient feedback. | We collect feedback after every treatment. 41 responses this quarter, two themes, and the change we made to aftercare calls. |
| Our staff are well trained. | A training matrix for every role, all mandatory training current, appraisals complete for all six staff. |
| We manage risk well. | A risk register reviewed every three months by someone who did not write it, and after every complaint or incident. |
How HIS uses it
HIS checks your self-evaluation when it plans an inspection, alongside your annual return, notifications and complaints, and uses it to inform its risk-based approach.5 One Glasgow clinic was recommended to complete and submit its self-evaluation when requested, and had done so by its follow-up in June 2026.6 How the answers feed into a grade is set out in the guide to HIS grades.
Questions
How often do I have to submit a self-evaluation?
When HIS asks. It writes to services periodically and sets a deadline in the email. It also checks the self-evaluation when planning an inspection.
Do single-handed practitioners complete every domain?
Every service completes domains 1, 3, 4, 5, 6 and 7. Domain 2, Leadership and culture, is only for services that employ staff, including people working under practising privileges.
Can I upload patient records as evidence?
No. HIS asks you not to upload anything with patient identifiable information, or anything it can find in care notes, which it samples at inspection.
Sources
- 1Healthcare Improvement Scotland, 2024Independent healthcare regulation, provider handbook, July 2024Read source
- 2Healthcare Improvement Scotland, 2023Independent healthcare Quality Assurance Framework, self-evaluation guidanceRead source
- 3Healthcare Improvement Scotland, 2023Independent healthcare Quality Assurance Framework, self-evaluation toolRead source
- 4Healthcare Improvement Scotland, 2022Quality Assurance Framework, September 2022Read source
- 5Healthcare Improvement Scotland, 2024Independent healthcare regulation, inspection methodology, July 2024Read source
- 6Healthcare Improvement Scotland, 2026Announced follow-up inspection report, an independent clinic in Glasgow, July 2026Read source
Written by the wai team from Healthcare Improvement Scotland guidance, checked on 15 October 2026. This is guidance, not legal advice. HIS does not endorse wai or any software.