How should you organise evidence for the National Standards for Safer Better Healthcare?

File evidence per national standard, grouped under HIQA's two dimensions, capacity and capability, and quality and safety, using the evidence examples in HIQA's judgment framework. Keep identifiable patient data out of anything you send, and let live records carry the rest.

The structure HIQA already uses

HIQA inspects against two dimensions. Capacity and capability checks the provider's ability to deliver the service sustainably and know what is happening in it. Quality and safety reviews the day-to-day experience of the people using the service.¹ For every standard the judgment framework gives its scope, related standards, what compliance may look like, and examples of the information and evidence HIQA may review.¹ Organise your evidence the same way and an inspector finds it where they expect it.

Live evidence and filed evidence

Some evidence is a document, a policy or a set of minutes. The rest is what happened, the healthcare record, the response to a complaint, the sequence of an incident. HIQA inspectors gather that through observation, records and conversations on the day.² An approved centre is held to the same idea under Regulation 27, which requires records kept complete, accurate, easy to retrieve, up to date and secured against loss, tampering and unauthorised access.³

1. Create one folder per standard. Numbered 1.1 to 8.3, under the two dimensions, mirroring the judgment framework.
2. Copy in HIQA's evidence examples. As a checklist at the top of each folder.
3. Separate filed from live evidence. Policies and minutes are filed, records and reports are produced from the system on the day.
4. Strip identifiable data. Nothing sent to HIQA should identify a patient or service user.
5. Date every item. So the inspector sees current evidence, never last year's.
6. Test retrieval. Ask a colleague to find the evidence for three standards in ten minutes.

1. Standard ______ Dimension ______
2. Filed evidence ______ Location ______
3. Live evidence, produced from ______
4. Date of latest item ______
5. Contains identifiable data, yes or no ______
6. Retrieval tested on ______ By ______

Copy template

Showing quality, beyond compliance

The Mental Health Commission invites approved centres to highlight best practice and progress in service improvement, with evidence such as learning, actions taken and improvements achieved, which the Inspector may use in the report.³ HIQA's reports likewise reflect good practice as well as what needs to improve.² Keep a short file of measured improvements beside the compliance evidence.

Questions

Can we send patient records to HIQA before an inspection?

No. HIQA asks providers not to send identifiable patient information or personal data, and inspectors review records on site.

What are HIQA's two dimensions?

Capacity and capability, and quality and safety, each holding several of the eight themes of the national standards.

Does the Mental Health Commission use the same framework?

No. It assesses approved centres against the regulations, Rules, Codes of Practice and Part 4 of the 2001 Act, using its Judgement Support Framework.

Sources

1. 1Health Information and Quality Authority, 2024Guidance on the Assessment Judgment Framework for the monitoring of healthcare services against the National Standards for Safer Better Healthcare, version 2.0, September 2024Read source
2. 2Health Information and Quality Authority, 2024A guide to healthcare inspections against the National Standards for Safer Better Healthcare, version 2.0, September 2024Read source
3. 3Mental Health Commission, 2026Judgement Support Framework 2026, for approved centre service providers, version 6.2, January 2026Read source

Written by the wai team from Health Information and Quality Authority guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither HIQA nor the Mental Health Commission endorses wai or any software.