Accessibility settings

This paper is in the following e-collection/theme issue:

Non-Randomized Study Protocols and Methods (Non-eHealth) (748) Policy and Policy Proposals (160) Policy Paper (18) Knowledge Translation and Implementation Science (587) E-Health / Health Services Research and New Models of Care (808) Digital Health Strategic Planning (28)

Published on in Vol 15 (2026)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/76945, first published .
Evaluating the Impact of Short-Notice Accreditation Assessment on Hospitals’ Patient Safety and Quality Culture: Protocol for a Mixed Methods Study

Evaluating the Impact of Short-Notice Accreditation Assessment on Hospitals’ Patient Safety and Quality Culture: Protocol for a Mixed Methods Study

Evaluating the Impact of Short-Notice Accreditation Assessment on Hospitals’ Patient Safety and Quality Culture: Protocol for a Mixed Methods Study

Authors of this article:

Robyn Scanlan1 Author Orcid Image ;   Tracy Flenady2 Author Orcid Image ;   Amy-Louise Byrne2 Author Orcid Image ;   Jenni Judd1 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    1Reseach Division, Central Queensland University, University Drive, Bundaberg, Australia

    2Central Queensland University, Rockhampton, Australia

    *these authors contributed equally

    Corresponding Author:

    Robyn Scanlan, BN, GradDipMid, MAdvNsgPrac, MBA, MPM


    Background: Accreditation programs are used by hospitals and health services to be independently reviewed against established safety and quality standards and have been a feature of global health systems for over a century. While evidence that accreditation programs directly improve patient safety and quality outcomes exists, the findings of various researchers remain mixed. Inefficiencies and a culture of “gaming” the system have also been observed, raising questions about the overall effectiveness of accreditation programs and assessment processes. Consequently, exploration of other formats of accreditation assessment, such as short-notice accreditation assessment, has arisen. From July 1, 2023, the Australian Commission on Safety and Quality in Healthcare mandated that Australian public and private hospitals must engage in short-notice accreditation assessment.

    Objective: This study aims to explore the impact of short-notice accreditation assessment on hospitals, both in terms of safety and quality indicators, and organizational culture. A mixed methods design will be used to investigate these impacts.

    Methods: Quantitative safety and quality indicators will be drawn from a regional health service prior to and following its first short-notice accreditation assessment cycle. From the same site, staff will be invited to complete the Patient Safety Culture Survey and participate in semistructured interviews. Using Schein’s Culture Framework as an organizational culture model, the study will examine observable outcomes (artifacts, behaviors, and indicators) alongside staff perceptions and experiences (norms and values) to form an understanding of underlying assumptions and beliefs about short-notice accreditation assessment processes. Quantitative data will be analyzed through cross-tabulation, trend analysis, and other statistical techniques, while qualitative data will be synthesized to provide a comprehensive understanding.

    Results: This protocol outlines the planned evaluation of short-notice accreditation assessment and its influence on patient safety and quality culture within a regional health service. Data collection is underway, with preintervention surveys being completed, and recruitment open for postintervention interviews. The study is expected to generate new knowledge on how this accreditation assessment process affects patient safety and quality culture of a regional and a rural hospital.

    Conclusions: The findings will inform health policy on the suitability and long-term viability of short-notice accreditation assessment as an approach to ensuring safe, high-quality health care.

    International Registered Report Identifier (IRRID): PRR1-10.2196/76945

    JMIR Res Protoc 2026;15:e76945

    doi:10.2196/76945

    Keywords

    mixed methods; health care quality; health care standards; staff perceptions; organizational culture 


    Accreditation programs are the process by which hospitals and health services are assessed against contemporary and evidence-based quality and safety standards [1,2] to ensure minimum standards of care delivery are embedded in the organizational functioning, and that such outcomes are received by the recipients of care [3,4].

    Accreditation programs in health care originated in the early 20th century as part of efforts to standardize hospital practices and improve patient care [3,5]. Initially, these processes were voluntary and focused on basic structural and procedural standards, such as sanitation and record-keeping. Over time, accreditation programs evolved into a comprehensive system of external evaluation, incorporating evidence-based standards and performance indicators to assess hospitals’ compliance with best practices [5,6]. Today, achievement of accreditation is widely recognized as a cornerstone of health care quality assurance globally, with most health service organizations (HSOs) viewing it as essential for maintaining public trust, meeting regulatory requirements, and driving continuous improvement [3]. In Australian hospitals, engagement in accreditation programs is now a mandated process for public and private services [7], and failure to meet specified standards can lead to regulatory consequences.

    Despite accreditation’s longevity in health care, debates persist about whether accreditation truly enhances patient outcomes or primarily promotes compliance behaviors rather than cultural transformation within organizations [6,8-10].

    The strong assumption that accreditation programs hold HSOs to the expected level of care delivery and continually improve quality is supported at some level by research and practice [3,6,8,11], with some comparative studies being inconclusive [6,9,10]. In their Evidence Brief, Deeble Institute for Health Policy Research [9] identifies that research into HSO accreditation is lacking, and, subsequently, the value and impact on quality and safety outcomes are ambiguous [9]. Interestingly, Hussein et al [8] identify that accreditation may support improvement in performance measures, but that there is inconclusive evidence to link accreditation with an improved patient safety culture.

    Many studies also demonstrate the unintended consequences of the established assurance processes [12-15]. Significantly, the resource investment into preparing and complying with an accreditation assessment has been reported to create additional burden and costs in engaging in accreditation [15-17]. Additionally, as accreditation outcomes may be publicly available, organizational actions that may pursue a positive result could be prioritized [18] over processes to achieve continuous patient care improvement [17-19]. This can result in inefficiencies in the standard accreditation process [6,19,20], a heavy investment in resources to achieve a successful outcome [18,20], and focus on compliance rather than quality [18,19].

    Indeed, contemporary literature increasingly critiques the adequacy of hospital accreditation in capturing the true culture and outcomes of HSOs. While accreditation is widely accepted as the mechanism for quality assurance, its effectiveness in driving meaningful cultural change remains contested. Lewis and Hinchcliff [21] argue that the body of research on accreditation is largely atheoretical and fails to explain how or why accreditation programs influence quality improvement, noting that most studies focus on compliance rather than cultural transformation. Similarly, Husseinet al [8] found that although accreditation programs may positively affect safety culture and process-related performance measures, their impact on patient outcomes such as satisfaction and readmission rates is inconsistent and often negligible. These findings suggest that attainment of accreditation may not be a reliable proxy for assessing the deeper, more nuanced aspects of organizational culture.

    Further, a growing concern in the literature is the phenomenon of “accreditation readiness” or “gaming the system,” where health services prepare intensively for scheduled assessments, potentially masking the everyday realities of care delivery. The concept of “Accreditation Theater,” as described by the Accreditation Commission for Health Care [22], highlights how punitive and performative assessment practices can create an illusion of rigor without advancing actual care quality. Tactics used during the accreditation assessment may include, but are not limited to, the distraction of accreditors to divert attention away from potential areas of noncompliance; rostering practices to ensure the most compliant staff are present during the assessment review; cognitive bias creation through relationship development with surveyors; and planning and timetabling ensuring areas of noncompliance are potentially hidden during accreditation reviews [19]. Brubakk, Vist [23] further emphasize that the push for accreditation persists despite scant evidence of its effectiveness, and that most studies fail to account for the context and implementation of accreditation processes, which are critical to understanding their true impact. These critiques underscore the need for accreditation models that move beyond episodic compliance checks and instead foster continuous cultural and quality improvement embedded in everyday practice.

    Nonetheless, HSOs generally support the value of accreditation programs, which are seen as essential in driving engagement with and developing collective quality improvement [8,24-26] and improvements in organizational cultures generally [27]. However, inefficiencies in the standard accreditation assessment process have raised questions about the value and effectiveness of a planned and cyclic accreditation procedure [8,28].

    To drive a continuous state of accreditation readiness, short-notice or unannounced formats of accreditation assessment have been introduced [28,29]. A short-notice accreditation assessment process provides the HSO with a short period of time (eg 48-hours’ notice) that surveyors will be onsite to undertake an assessment; and an unannounced accreditation assessment process provides no notice to the HSO that surveyors will be onsite to undertake an assessment. Notably, the American health care accreditation body, the Joint Commission, introduced unannounced visits in 2006 with the goal of ensuring quality care at all times, built on the premise that it was the “right thing to do” [30]. More recently, the Danish Institute for Quality and Accreditation in Healthcare undertook a trial of unannounced accreditation surveys [19]. Ehlers et al [19] found that unannounced accreditation surveys were not more effective in detecting quality issues in hospitals; however, the study did not examine the impact of an unannounced model on the safety and quality culture of HSOs. Subsequently, an Australian-first trial of a short-notice accreditation assessment occurred in 2017, resulting in changes to the Australian Health Service Safety and Quality Accreditation Scheme (AHSSQAS) mandating short-notice accreditation assessment processes for all Australian public and private hospitals [7,17,20].

    Those Australian HSOs engaged in short-notice accreditation assessment trial argue this type of process ensures assessment results reflect the reality of the HSO safety and quality environment, and embeds a culture of quality and safety functioning within the daily practice, thus improving patient care [20], experience [31], and outcomes [20]. Importantly, short-notice accreditation assessment offers an alternative to traditional accreditation assessment processes, which may reduce opportunities for gaming. Indeed, short-notice or unannounced assessment processes of accreditation have been proposed to minimize the resource investment in preparing for accreditation [7,20], support the reliability of the accreditation outcomes [17,20,28], and reposition the accreditation program as a tool to support HSOs’ quality and safety agenda [20,29].

    Despite the change to a new format of accreditation assessment, there is a paucity of evidence that supports the use of a short-notice assessment process [19,28], and little research that explores the impact that this process has on the culture of quality and safety for a health service. Scanlan et al [32] concluded that there is limited evidence reporting on the effectiveness of short-notice accreditation assessment models used by hospitals, and that there are no studies undertaken which seek to understand the impact a short-notice accreditation assessment model can have on patient safety and quality cultures. As such, this study protocol details a mixed methods study which uses Schein’s Culture Framework [33] as a theoretical model within a postpositivism paradigm to evaluate the impact of a short-notice accreditation assessment.


    Research Aims

    This research aims to understand the impact of short-notice accreditation assessment processes on HSO patient safety and quality culture, and to understand the impact of a short-notice accreditation assessment process from a safety and quality indicator perspective.

    Research Objectives

    The research objectives are as follows:

    1. Measure and compare HSOs' safety and quality key performance indicators before and after the short-notice accreditation assessment.
    2. Evaluate the effectiveness of short-notice accreditation in increasing individual accountability and translating safety and quality standards into clinical practice.
    3. Assess the extent to which short-notice accreditation embeds a sustainable safety and quality culture within the organization.

    Theoretical Framework

    This study adopts a postpositivist orientation consistent with its mixed methods design and focus on empirical evaluation of organizational outcomes. Postpositivism supports the use of quantitative indicators to examine patterns and relationships in safety and quality performance, while also recognizing the value of qualitative inquiry to explore staff perceptions and experiences that cannot be fully captured through measurement alone.

    Schein’s Culture Framework [33] provides a pragmatic structure for integrating these data sources by linking observable organizational artifacts and behaviors with reported norms, values, and assumptions. This approach enables a comprehensive examination of how short-notice accreditation processes may influence patient safety and quality culture without requiring commitment to a single explanatory theory of organizational reality.

    Measuring organizational culture is notoriously difficult and complex [34], with agreed indicators lacking [35]. In simplest terms, culture is the pattern of shared basic assumptions within a group [33]. Typically, HSOs focus on the observable and easily measured outcomes to infer the underlying culture of their organization [36,37]. Research into determinants of positive patient safety and quality health outcomes indicates culture is a significant driver [38-42]; however, limited information in triangulating accreditation, health service outcomes, and culture exists [43-46].

    No standard tool for measuring organizational culture of complex systems such as HSOs exists; however, the Schein Cultural Framework [33] remains constant in published approaches [47-49]. Cacciattolo [50] synthesized contemporary knowledge and research into applying models for understanding and analyzing organizational culture, finding that 2 main approaches to understanding organizational culture exist: interpretive and structural [50]. The Schein Culture Framework [33] fits within the structural approach [50] and provides a valuable model for understanding a culture’s influence on HSO indicators. Hogan and Coote [51] and Cacciattolo [50] have identified the Framework’s wide acceptance and practical application for understanding and influencing organizational cultural change. While Hogan and Coote [51] have recognized the limited research validating Schein’s Culture Framework [33], they have also demonstrated the value of using the model to build a positive organizational culture [51]. Understanding the determinants of a positive patient safety and quality culture within the health care setting is central to this study, and Schein’s Culture Framework [33] was determined to be beneficial in devising this research approach.

    Schein’s Culture Framework [33] is particularly well-suited for evaluating organizational culture in health care settings due to its multilayered approach that captures both visible and invisible dimensions of culture [49]. Compared to other models, Schein’s [33] framework is uniquely positioned to explore organizational-level culture in complex systems like hospitals. Indeed, Schein’s Cultural Framework [33] excels in diagnosing and influencing culture within specific institutions by acknowledging the interplay between structure, meaning, and behavior. Moreover, its compatibility with critical realism, as discussed by Khaddour [52], supports a nuanced understanding of culture that avoids oversimplification and embraces complexity, making it ideal for mixed methods research in health care. This theoretical robustness and practical applicability justify its use in studies aiming to assess the cultural impact of short-notice accreditation processes.

    Schein [33] proposes a culture framework where understanding the norms, values, and underlying assumptions can be linked to the observable outcomes of organizational indicators (Figure 1).

    ‎
    Figure 1. Schein’s [33] culture framework.

    Using the Schein [33] Culture Framework as a model, the research will consider the effectiveness of a short-notice accreditation assessment process to embed a culture of safety and quality, demonstrated through observable outcomes in organizational indicators. The research will test the underlying but inconclusive belief that accreditation and, subsequently, short-notice accreditation assessment improves patient safety and quality outcomes.

    Design

    Considering both organizational culture and impact on quantitative and qualitative indicators lends this research to a mixed methods approach and triangulation of the resultant data through a convergent design process [53]. A mixed methods approach to the research will be used with reporting adhering to the GRAMMS (Good Reporting of A Mixed Methods Study) [54] guidelines.

    Using a convergent mixed methods design, the research methods and data collection will progress as per the basic flowchart in Figure 2.

    ‎
    Figure 2. Mixed methods design.

    (Adapted from Creswell [53]). Hogden et al [55] identified that a mixed methods approach is advocated when evaluating health care safety culture [55]. Their literature review identified that no individual tool could evaluate the safety culture and recommended that a mixed methods assessment of culture as one of the approaches that could be taken [55].

    The quantitative data strand will use descriptive and inferential analysis methods. Descriptive statistical methods summarize, describe, and draw conclusions on the population or datasets, while inferential statistical methods use the sample to draw conclusions and make predictions [56]. For the qualitative branch, coding and thematic analysis will be used. Both data strands will be merged to compare, contrast, and synthesize the information, leading to interpretation and reporting, as per Figure 2.

    Table 1 illustrates how the anticipated research measures map to Schein’s Culture Framework levels [33].

    Table 1. Anticipated research measures versus Schein’s [33] culture framework levels.
    Schein’s levelsDefinitionAnticipated research measures
    Artifacts and behaviorsWhat we see
    Observable outcomes    		Established health service safety and quality indicators
    Norms and valuesWhat they say
    What is the reason why things are the way they are    		Staff perceptions and experience
    Basic underlying assumptionsWhat is assumed
    Unconscious beliefs    		Accreditation improves patient safety (not a measure, but an underlying belief or assumption)

    Research Environment

    The research will be conducted in one Queensland (Australia) public HSO. The research will include two hospitals: a 331-bed regional hospital and a 36-bed rural hospital. Both hospitals provide various medical services, including emergency, inpatient, outpatient, and allied health services. While the short-notice accreditation format of assessment has been mandated since July 1, 2023, this HSO has yet to engage in their first short-notice accreditation assessment. Including both hospitals from this HSO offers an opportunity to evaluate the applicability of a short-notice accreditation assessment process across various contexts. Importantly, the research environment is shaped not only by the characteristics of the hospitals themselves but also by the external factors such as policy or funding shifts, which may influence organizational culture. By selecting hospitals within the same service area, the researcher can better account for these contextual influences. Interview questions will further explore organizational norms, values, and underlying assumptions about accreditation processes that underpin a patient safety and quality culture.

    Data

    Overview

    A scoping review [32] conducted by the research team identified gaps in understanding the impact of short-notice accreditation. Based on these findings, the study will focus on three components of data collection: (1) safety and quality indicators, (2) patient safety culture surveys, and (3) staff interviews.

    All safety and quality indicators, as well as participants for the surveys and interviews, will be drawn from the regional HSO in which the study is being conducted. Figure 3 provides a graphical representation of the data collection timeline.

    ‎
    Figure 3. Data collection timeline.

    Data from all domains will be collected longitudinally. Safety and quality indicators will be examined for the 12 months preceding the HSO’s first short-notice accreditation assessment to establish baseline trends. Because the HSO will not know the exact timing of their assessment, these 12 months of preassessment data will serve as the baseline. Postassessment data will then be collected for 6 months following the first short-notice accreditation assessment, enabling comparison to determine whether the assessment influenced safety and quality indicators. While shorter than the pre-period, the 6-month time frame postassessment is adequate to identify trends pre- and postaccreditation assessment and to inform researchers of future research direction.

    Patient safety culture surveys will be administered both before and after the first short-notice accreditation assessment. Staff interviews will be conducted after the accreditation assessment, allowing participants to reflect on and compare their experiences of previous accreditation processes with the new short-notice format.

    Safety and Quality Indicators

    HSOs routinely collect quality and safety indicators as part of their routine governance [37,57]. The indicators are widely recognized as being linked to hospital performance, safety culture, and patient outcomes [36]. Numerous studies have also used clinical quality and safety indicators to evaluate the impact of accreditation processes [19,29,57,58].

    In Australia, HSOs establish safety and quality indicators in alignment with the National Safety and Quality Standards [1] which are reliably collected against agreed data specifications. For this study, standard indicators aligned to the National Safety and Quality Standards [59] will be used.

    Table 2 presents the indicator population used within the research study.

    Table 2. Safety and quality indicators.
    National safety and quality standardProcess and outcome indicator setBalancing or linking indicators
    Standard 1 – Clinical Governance
    • Hospital standardized mortality ratio
    • Deaths in low-risk diagnostic related groups Registered quality improvements
    • Severity assessment code 1 clinical incident rates
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index
    Standard 2 – Partnering with Consumers
    • Patient reported experience measures
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index
    Standard 3 – Infection Control
    • Hospital acquired infections
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index
    Standard 4 – Medication Safety
    • Reported medication incidents – severity assessment code 1 and 2
    • Medication complications
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index
    Standard 5 – Comprehensive Care
    • Pressure injuries, falls, malnutrition, delirium
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index
    Standard 6 – Communicating for Safety
    • Discharge summary completion rates
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index
    Standard 7 – Blood Management
    • Hemovigilance incidents – severity assessment code 1 and 2
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index
    Standard 8 – Recognizing and Responding to Acute Deterioration
    • Deterioration scoring
    • Response escalation
    • Rapid response calls
    • Deterioration patient incidents - severity assessment code 1 and 2
    • Patient or family escalation of care
    • Readmission rates
    • Unplanned return to theater
    • Length of stay
    • Relative stay index

    This quantitative data will be sourced from health service-specific repositories accessible to the research team under the ethics approval protocol. Indicators will be collected for a period beginning 12 months prior to the HSO’s first short-notice accreditation assessment and extending to 6 months post assessment. This timeframe provides both a preassessment baseline and a postassessment follow-up. In contrast to the traditional 3 to 4-year accreditation cycle, this design allows a timely assessment of the potential influence of the short-notice accreditation process on organizational safety and quality indicators.

    Patient Safety Culture Surveys

    The assessment of a HSO's safety culture is mandated by Australian governing bodies [59]. To support this, the Australian Commission on Safety and Quality in Health Care [60] recently released the Australian Hospital Survey on Patient Safety Culture 2.0 (A-HSOPS 2.0) under a Creative Commons license. The validated tool, specifically designed for use within Australian hospitals, will be used to capture staff perceptions of safety culture within the participating HSO. The survey can be securely administered online, allowing staff to provide responses anonymously.

    Participation will be voluntary, with the target sample drawn from the population of staff of the HSO undergoing short-notice accreditation. Based on a 90% CI, the required sample size is 66 clinical staff [61]. As the questionnaire records respondents’ professional role, alignment between the response profile and the overall staffing profile will further support the validity of findings.

    To ensure confidentiality, the survey will not collect identifying data beyond: (1) role in the organization, (2) department of employment, (3) years of service in the organization, and (4) gender.

    These demographic variables will enable comparison of survey respondents with the overall staff population, while aggregated reporting will minimize any risk of re-identification.

    Staff Interviews

    To supplement the quantitative findings from the HSO quality and safety indicators and safety culture surveys, semistructured staff interviews will be undertaken to provide clarification and contextualization. This qualitative component will help validate and deepen the interpretation of the quantitative data. Semistructured interviews, using open-ended questions, will elicit greater depth and understanding of the subjects’ experience [61]. Participants will be drawn from across the HSO undergoing short-notice accreditation, with representation sought from all organizational levels, including executive, governance, clinical, support, and operational staff. Participation will be voluntary.

    Interview guides will be informed by analysis of indicators and survey data with questions designed to explore areas where findings may be limited, unclear, or conflicting (Multimedia Appendix 1). Further, interviews will focus on staff’s perceptions of short-notice accreditation, their experience of organizational culture, and the extent to which these domains may intersect.

    Data Analysis

    Organizational Quality and Safety Indicators

    Data from organizational safety and quality indicators will be reviewed in relation to accreditation processes. Cross-tabulation, trend analysis, and statistical analysis techniques will be applied. Both descriptive and inferential statistical methodologies will be used to provide a comprehensive understanding of indicator trends and their relationship to short-notice accreditation [61].

    Staff Safety Culture Surveys

    Survey responses will generate statistical data reflecting staff’s perceptions of safety culture. Cross-trend analysis and inferential techniques, including ANOVA, will be applied to compare differences across staff groups and over time. As with the indicator data, descriptive and inferential statistics will be used to build a comprehensive understanding of patterns and changes [61]. Data will be exported from Qualtrics for a pre- and poststatistical analysis through time-series comparison.

    Staff Interviews

    Interview transcripts will be analyzed using a qualitative data analysis approach, with coding to identify patterns, themes, and relationships between short-notice accreditation processes and organizational culture. Braun and Clarke [62] 6-phase thematic analysis framework will guide the analysis, ensuring a rigorous and systematic interpretation of staff experiences and perspectives.

    Data Compilation and Report Writing

    Data compilation and report writing will occur during steps 3 and 4 of the convergent mixed methods process.

    Table 3 provides an overview of data sources aligned with Schein’s [33] organizational culture levels and illustrates how each research artifact addresses the research questions.

    Table 3. Overview of data compilation.
    Schein levelResearch questionResearch artifactPopulationAnalysis
    Artifacts and behaviorsWhat impact does a short-notice accreditation process have on a health service organization’s core safety and quality indicators?Quantitative analysis of organizational quality and safety indicatorsListed in indicators in Table 1 from a single Hospital and Health ServiceStatistical analysis
    Trend over time-correlated to short-notice accreditation cycles and historical accreditation processes
    Norms and valuesWhat impact do accreditation processes have on the perceptions of health service organizational safety and quality culture?Use of mixed methods
    • Staff Safety Culture Surveys
    • Qualitative Staff Interviews
    		Representative staff at all levels (ward to executive)
    Nonclinical, clinical, management, executive from a single Hospital and Health Service    		Using mixed methods protocols:
    • Survey statistical analysis
    • Thematic analysis
    Basic underlying assumptionWhat impact does a short-notice accreditation process have on a health service’s organizational safety and quality?
    How does a short-notice accreditation process support a health service organization’s ability to embed a safety and quality culture?    		What impact does a short-notice accreditation process have on a health service’s organizational safety and quality?
    How does a short-notice accreditation process support a health service organization’s ability to embed a safety and quality culture?    		What impact does a short-notice accreditation process have on a health service’s organizational safety and quality?
    How does a short-notice accreditation process support a health service organization’s ability to embed a safety and quality culture?    		Merging of qualitative and quantitative data identifying differences and similarities
    Interpretation and reporting of merged results to answer the question

    Table 3 identifies the primary research question for this project. When the datasets are converged, joint displays and triangulation will occur during interpretation, thus contributing to addressing the primary research question.

    The qualitative and quantitative strands of data will then be merged for comparative analysis. This process will enable triangulation of findings, allowing discrepancies and inconsistencies to be interrogated and similarities and differences to be explored. The convergent design ensures that outcomes are interpreted in alignment with Schein’s Culture Framework [33], strengthening the validity of the findings. Where divergences are evident, further analysis will be undertaken to provide an increased understanding of the synthesized results.

    Ethical Considerations

    This project has been approved by Queensland Health Human Research Ethics Committee, approval number LNR/2022/QGC/84035 (August 4, 2022), and CQUniversity Human Research Ethics Committee, approval number 0000023861 (September 14, 2022).


    The study is currently collecting the preintervention of patient safety and quality survey data prior to the HSO engaging in their first short-notice accreditation process (Figure 3). Through the survey data collection, the study is also enrolling interested participants for postintervention interviews. Final data and results are expected to be completed 6 months after the short-notice accreditation process. The date of this process is not known to the HSO nor the researchers.


    Anticipated Findings

    This study protocol outlines research designed to evaluate the impact of a short-notice accreditation process on the patient safety and quality culture of a health care organization. Existing research in health service accreditation provides limited insight into short-notice accreditation influences organizational culture, and this study aims to contribute to addressing that gap.

    In their scoping review, Scanlan et al [32] identified limited and sometimes conflicting evidence on the value of short-notice accreditation processes. The reviewed literature, findings were inconsistent in demonstrating whether accreditation improved safety and quality performance [18,19,27,63]. This lack of consensus highlights the importance of further research to provide robust evidence on the cultural and organizational impacts of short-notice accreditation.

    With the recent mandate requiring short-notice accreditation within the Australian accreditation scheme [17], there is a clear imperative to understand the effectiveness of such a format. Grounding this research in Schein’s Culture Framework [33] provides a structured lens through which to examine organizational culture across artifacts and behaviors, norms and values, and basic underlying assumptions. When combined with a mixed methods design, this approach allows for a comprehensive exploration of how short-notice accreditation may shape patient safety and quality culture. Findings from this study have the potential to inform both national and international health policy, while also extending the validation of Schein’s Culture Framework [33] in health care settings.

    Limitations

    This study is limited to 2 hospitals within a single regional HSO. While findings will provide valuable insights into the impact of short-notice accreditation in this context, the applicability of results to larger, metropolitan, or differently structured services can only be inferred and will not be directly examined within the scope of this protocol.

    An important limitation of this study is the potential influence of external factors on both the organizational culture and the safety and quality indicators being measured. The unpredictable timing of short-notice accreditation assessments means that data collection may coincide with broader systemic changes such as policy reforms, funding adjustments, seasonal fluctuations in patient demand, or workforce transitions. These factors can independently affect staff perceptions, organizational performance, and cultural dynamics, making it difficult to isolate the impact of accreditation alone. For example, staffing shortages or leadership changes during the data collection period may skew survey responses or interview narratives, while external policy shifts could influence indicator trends unrelated to accreditation. Although the study design attempts to mitigate these risks by selecting hospitals within the same HSO, the complexity of health care environments means that such confounding variables cannot be fully controlled. Future research may benefit from multi-site studies or longitudinal designs that better account for these contextual influences.

    The staff safety culture survey and interviews also introduce methodological constraints. Survey participation is voluntary and may be subject to low response rates or response bias, with some staff groups under-represented. Interview participants, while purposively sampled to represent all organizational levels, may not reflect the full diversity of staff experiences. In addition, reliance on self-report raises the possibility of social desirability or recall bias. Finally, the study applies Schein’s Culture Framework as its theoretical lens. While this provides a structured approach to examining organizational culture, it may not capture all relevant dimensions that influence how accreditation processes shape safety and quality culture.

    Conclusions

    The short-notice accreditation format of assessment has been introduced into the AHSSQAS to strengthen and improve accreditation processes. However, evidence on whether this format enhances patient safety and quality culture remains limited. By applying Schein’s Culture Framework [33] within a mixed methods design, this study seeks to generate new knowledge on the organizational impact of short-notice accreditation. Findings will contribute to understanding how accreditation influences the artifacts, values, and underlying assumptions that shape patient safety and quality culture in HSOs. In doing so, the research aims to inform both policy and practice, nationally and internationally, on the effectiveness of short-notice accreditation as a strategy for improving safety and quality in health care.

    Acknowledgments

    This protocol is the original work of the authors. The first author made substantial contributions to the conception and design of the protocol. All authors have made substantial contributions to the drafting of the protocol. The second and third authors made substantial contributions to the critical revision of the protocol. All authors approve the final manuscript. All authors prepared and submitted ethics applications.

    All authors attested that generative artificial intelligence has not been used in any portion of the manuscript generation.

    Funding

    Research Higher Degree (RHD) candidate funding has been received. The authors acknowledge the support of the Australian Government.

    Authors' Contributions

    Conceptualization, formal analysis, investigation, writing – original draft, writing – review and editing, and visualization: RLS

    Conceptualization, formal analysis, writing – review and editing, and supervision: TF

    Conceptualization, formal analysis, writing – review and editing, and supervision: JJ

    Conceptualization, writing – review and editing, and supervision: ALB

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    Sample interview questions.

    DOCX File, 14 KB
    1. McPhail R, Avery M, Fisher R, Fitzgerald A, Fulop L. The changing face of healthcare accreditation in Australia. Asia Pacific Journal of Health Management. 2015;10(2):58-64. URL: https:/​/research-repository.​griffith.edu.au/​server/​api/​core/​bitstreams/​f74bc22a-e608-5503-a749-e37c41e800ff/​content [Accessed 2026-04-09]
    2. Scrivens E. Accreditation and the regulation of quality in health services. In: Regulating Entrepreneurial Behaviour in European Health Care Systems. Open University Press; 2002:91-105. URL: https:/​/www.​researchgate.net/​profile/​Ana-Rico-3/​publication/​282858573_What_can_we_learn_from_the_regulation_of_public_utilities/​links/​561f97d108aea35f267dee94/​What-can-we-learn-from-the-regulation-of-public-utilities.​pdf#page=107 [Accessed 2026-04-14]
    3. World Health Organization. Health care accreditation and quality of care: exploring the role of accreditation and external evalutation of health care facilities and organizations. 2022. URL: https://www.who.int/publications/i/item/9789240055230 [Accessed 2026-04-09]
    4. Pomey MP, Lemieux-Charles L, Champagne F, Angus D, Shabah A, Contandriopoulos AP. Does accreditation stimulate change? A study of the impact of the accreditation process on Canadian healthcare organizations. Implement Sci. Apr 26, 2010;5(1):31. [CrossRef] [Medline]
    5. Alkhenizan A, Shaw C. Impact of accreditation on the quality of healthcare services: a systematic review of the literature. Ann Saudi Med. 2011;31(4):407-416. [CrossRef] [Medline]
    6. Araujo CAS, Siqueira MM, Malik AM. Hospital accreditation impact on healthcare quality dimensions: a systematic review. Int J Qual Health Care. Nov 9, 2020;32(8):531-544. [CrossRef] [Medline]
    7. Fact sheet 17: short notice accreditation assessment. Australian Commission on Safety and Quality in Health Care; 2024:8. URL: https:/​/www.​safetyandquality.gov.au/​publications-and-resources/​resource-library/​fact-sheet-17-short-notice-accreditation-assessment [Accessed 2026-04-09]
    8. Hussein M, Pavlova M, Ghalwash M, Groot W. The impact of hospital accreditation on the quality of healthcare: a systematic literature review. BMC Health Serv Res. Oct 6, 2021;21(1):1057. [CrossRef] [Medline]
    9. Deeble Institute for Health Policy Research. Evidence brief 18: assessing the value of accreditation to health systems and organisations. Deeble Institute; 2019. URL: https:/​/ahha.​asn.au/​wp-content/​uploads/​2024/​04/​Evidence-Brief-No.​18-Assessing-the-value-of-accreditation.​pdf [Accessed 2026-04-09]
    10. Van Wilder A, Bruyneel L, De Ridder D, et al. Is a hospital quality policy based on a triad of accreditation, public reporting and inspection evidence-based? A narrative review. Int J Qual Health Care. May 28, 2021;33(2):mzab085. [CrossRef] [Medline]
    11. Hinchcliff R, Greenfield D, Moldovan M, et al. Narrative synthesis of health service accreditation literature. BMJ Qual Saf. Dec 2012;21(12):979-991. [CrossRef] [Medline]
    12. Engel C, Andersen HB. Side effects of overdoing it: lessons from a comprehensive hospital accreditation programme. In: Researching Patient Safety and Quality in Healthcare. CRC Press; 2016:115-127. URL: https:/​/www.​taylorfrancis.com/​chapters/​edit/​10.1201/​9781315605609-10/​side-effects-overdoing-carsten-engel-henning-boje-andersen [Accessed 2026-04-14] [CrossRef]
    13. Ho MJ, Chang HH, Chiu YT, Norris JL. Effects of hospital accreditation on medical students: a national qualitative study in Taiwan. Acad Med. Nov 2014;89(11):1533-1539. [CrossRef] [Medline]
    14. Katoue MG, Somerville SG, Barake R, Scott M. The perceptions of healthcare professionals about accreditation and its impact on quality of healthcare in Kuwait: a qualitative study. J Eval Clin Pract. Dec 2021;27(6):1310-1320. [CrossRef] [Medline]
    15. Mosadeghrad AM. Hospital accreditation: the good, the bad, and the ugly. Int J Healthc Manag. Oct 2, 2021;14(4):1597-1601. [CrossRef]
    16. Mumford V, Forde K, Greenfield D, Hinchcliff R, Braithwaite J. Health services accreditation: what is the evidence that the benefits justify the costs? Int J Qual Health Care. Oct 2013;25(5):606-620. [CrossRef] [Medline]
    17. Review of the Australian health service safety and quality accreditation scheme: improving the reliability of health service organisation accreditation processes. Australian Commission on Safety and Quality in Health Care; 2018. URL: https:/​/www.​safetyandquality.gov.au/​sites/​default/​files/​2019-06/​review-of-the-australian-health-service-safety-and-quality-accreditation-scheme-improving-the-reliability-of-health-service-organisation-accreditation-processes-0.​pdf [Accessed 2026-04-09]
    18. Aghaei Hashjin A, Delgoshaei B, Kringos DS, Tabibi SJ, Manouchehri J, Klazinga NS. Implementing hospital quality assurance policies in Iran: balancing licensing, annual evaluation, inspections and quality management systems. Int J Health Care Qual Assur. 2015;28(4):343-355. [CrossRef] [Medline]
    19. Ehlers LH, Simonsen KB, Jensen MB, Rasmussen GS, Olesen AV. Unannounced versus announced hospital surveys: a nationwide cluster-randomized controlled trial. Int J Qual Health Care. Jun 1, 2017;29(3):406-411. [CrossRef]
    20. Uren H, Vidakovic B, Daly M, Sosnowski K, Matus V. Short-notice (48 hours) ACCREDITATION trial in Australia: stakeholder perception of assessment thoroughness, resource requirements and workforce engagement. BMJ Open Qual. 2019;8(3):e000713. [CrossRef] [Medline]
    21. Lewis K, Hinchcliff R. Hospital accreditation: an umbrella review. Int J Qual Health Care. Feb 24, 2023;35(1):mzad007. [CrossRef] [Medline]
    22. Accreditation theater: the illusion of rigor in healthcare accreditation. Accreditation Commission for Health Care; 2025. URL: https://achc.org/accreditation-theater-the-illusion-of-rigor-in-healthcare-accreditation/ [Accessed 2026-04-09]
    23. Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res. Jul 23, 2015;15:280. [CrossRef] [Medline]
    24. Desveaux L, Mitchell JI, Shaw J, Ivers NM. Understanding the impact of accreditation on quality in healthcare: a grounded theory approach. Int J Qual Health Care. Nov 1, 2017;29(7):941-947. [CrossRef] [Medline]
    25. Mitchell JI, Graham ID, Nicklin W. The unrecognized power of health services accreditation: more than external evaluation. Int J Qual Health Care. Sep 23, 2020;32(7):445-455. [CrossRef] [Medline]
    26. Jha AK. Accreditation, quality, and making hospital care better. JAMA. Dec 18, 2018;320(23):2410-2411. [CrossRef] [Medline]
    27. Devkaran S, O’Farrell PN, Ellahham S, Arcangel R. Impact of repeated hospital accreditation surveys on quality and reliability, an 8-year interrupted time series analysis. BMJ Open. Feb 15, 2019;9(2):e024514. [CrossRef] [Medline]
    28. Hinchcliff R, Glennie M, Travaglia J, Carter D, Billington L, Debono D. Short notice and unannounced survey methods: literature review. Australian Commission on Safety and Quality in Health Care; 2017. URL: https:/​/www.​safetyandquality.gov.au/​sites/​default/​files/​migrated/​Short-Notice-and-Unannounced-Survey-Methods-Literature-review.​pdf [Accessed 2026-04-09]
    29. Barnett ML, Olenski AR, Jena AB. Patient mortality during unannounced accreditation surveys at US hospitals. JAMA Intern Med. May 1, 2017;177(5):693-700. [CrossRef] [Medline]
    30. Hall A. State of the surveys: 18 months of joint commission unannounced visits. Biomed Instrum Technol. Jul 2007;41(4):309-310. [CrossRef]
    31. Bergholt MD, Falstie-Jensen AM, Brink Valentin J, et al. Patients experience more support, information and involvement after first-time hospital accreditation: a before and after study in the Faroe Islands. Int J Qual Health Care. Nov 12, 2021;33(4):mzab149. [CrossRef] [Medline]
    32. Scanlan R, Flenady T, Judd J. Impact of short-notice accreditation assessments on hospitals’ patient safety and quality culture-a scoping review. J Adv Nurs. Oct 2024;80(10):3965-3976. [CrossRef] [Medline]
    33. Schein EH. Organizational Culture and Leadership. John Wiley and Sons; 2017. ISBN: 1119212057 1119212138
    34. Allen S, Chiarella M, Homer CSE. Lessons learned from measuring safety culture: an Australian case study. Midwifery. Oct 2010;26(5):497-503. [CrossRef] [Medline]
    35. Alsalem G, Bowie P, Morrison J. Assessing safety climate in acute hospital settings: a systematic review of the adequacy of the psychometric properties of survey measurement tools. BMC Health Serv Res. May 10, 2018;18(1):353. [CrossRef] [Medline]
    36. Brown DS, Wolosin R. Safety culture relationships with hospital nursing sensitive metrics. J Healthc Qual. 2013;35(4):61-74. [CrossRef] [Medline]
    37. Kristensen S, Mainz J, Bartels P, Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety: recommendations of the project “safety improvement for patients in Europe”. Int J Qual Health Care. Jun 2009;21(3):169-175. [CrossRef] [Medline]
    38. Chatburn E, Macrae C, Carthey J, Vincent C. Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice. BMJ Qual Saf. Oct 2018;27(10):818-826. [CrossRef] [Medline]
    39. Ginsburg L, Gilin Oore D. Patient safety climate strength: a concept that requires more attention. BMJ Qual Saf. Sep 2016;25(9):680-687. [CrossRef] [Medline]
    40. Kalteh HO, Mortazavi SB, Mohammadi E, Salesi M. The relationship between safety culture and safety climate and safety performance: a systematic review. Int J Occup Saf Ergon. Mar 2021;27(1):206-216. [CrossRef] [Medline]
    41. Steyrer J, Schiffinger M, Huber C, Valentin A, Strunk G. Attitude is everything? The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units. Health Care Manage Rev. 2013;38(4):306-316. [CrossRef] [Medline]
    42. DiCuccio MH. The relationship between patient safety culture and patient outcomes: a systematic review. J Patient Saf. Sep 2015;11(3):135-142. [CrossRef] [Medline]
    43. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. May 2011;39(5):934-939. [CrossRef] [Medline]
    44. Caris MG, Kamphuis PGA, Dekker M, de Bruijne MC, van Agtmael MA, Vandenbroucke-Grauls C. Patient safety culture and the ability to improve: a proof of concept study on hand hygiene. Infect Control Hosp Epidemiol. Nov 2017;38(11):1277-1283. [CrossRef] [Medline]
    45. Carrothers KM, Barr J, Spurlock B, Ridgely MS, Damberg CL, Ely EW. Contextual issues influencing implementation and outcomes associated with an integrated approach to managing pain, agitation, and delirium in adult ICUs. Crit Care Med. Sep 2013;41(9 Suppl 1):S128-S135. [CrossRef] [Medline]
    46. Jones L, Pomeroy L, Robert G, Burnett S, Anderson JE, Fulop NJ. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf. Dec 2017;26(12):978-986. [CrossRef] [Medline]
    47. Simpson D, Hamilton S, McSherry R, McIntosh R. Measuring and assessing healthcare organisational culture in the England’s National Health Service: a snapshot of current tools and tool use. Healthcare (Basel). Nov 1, 2019;7(4):127. [CrossRef] [Medline]
    48. Mannion R, Davies H. Understanding organisational culture for healthcare quality improvement. BMJ. Nov 28, 2018;363:k4907. [CrossRef] [Medline]
    49. Feng X, Bobay K, Weiss M. Patient safety culture in nursing: a dimensional concept analysis. J Adv Nurs. Aug 2008;63(3):310-319. [CrossRef] [Medline]
    50. Cacciattolo K. Understanding organisational cultures. Eur Sci J. 2014;2(1):1-7. URL: https://eujournal.org/index.php/esj/article/view/4782 [Accessed 2026-04-16]
    51. Hogan SJ, Coote LV. Organizational culture, innovation, and performance: a test of Schein’s model. J Bus Res. Aug 2014;67(8):1609-1621. [CrossRef]
    52. Khaddour WN. Critical realism and organizational culture—framing Schein’s model of studying organizational culture by using critical realism philosophy. OJPP. 2025;15(1):77-97. [CrossRef]
    53. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Sage Publications; 2009. ISBN: 978-1-4129-6556-9
    54. O’Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy. Apr 2008;13(2):92-98. [CrossRef] [Medline]
    55. Hogden A, Ellis LA, Churruca K, Bierbaum M. Safety Culture Assessment in Health Care: A Review of the Literature on Safety Culture Assessment Modes. Australian Commission on Safety and Quality in Health Care; 2017. URL: https:/​/www.​safetyandquality.gov.au/​sites/​default/​files/​migrated/​Safety-Culture-Assessment-in-Health-Care-A-review-of-the-literature-on-safety-culture-assessment-modes.​pdf [Accessed 2026-04-14]
    56. Sutanapong C, Louangrath PI. Descriptive and inferential statistics. International Journal of Research & Methodology in Social Science. 2015;1(1):14. URL: https:/​/www.​studocu.com/​ph/​document/​polytechnic-university-of-the-philippines/​bs-chemistry/​descriptive-and-inferential-statistics-vol-1-no-1/​64173726 [Accessed 2026-04-14]
    57. Collopy BT. Clinical indicators in accreditation: an effective stimulus to improve patient care. Int J Qual Health Care. Jun 2000;12(3):211-216. [CrossRef] [Medline]
    58. Mumford V, Reeve R, Greenfield D, Forde K, Westbrook J, Braithwaite J. Is accreditation linked to hospital infection rates? A 4-year, data linkage study of Staphylococcus aureus rates and accreditation scores in 77 Australian acute hospitals. Int J Qual Health Care. Dec 2015;27(6):479-485. [CrossRef] [Medline]
    59. National Safety and Quality Standards 2nd Edition: User Guide for Governing Bodies. Australian Commision on Safety and Quality in Health Care; 2019. URL: https:/​/www.​safetyandquality.gov.au/​publications-and-resources/​resource-library/​nsqhs-standards-user-guide-governing-bodies [Accessed 2026-04-14]
    60. A-HSOPS 20 survey form. Australian Commission on Safety and Quality in Health Care. URL: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/hsops-20-survey-form [Accessed 2026-04-14]
    61. O’Leary Z, Tennent E. The Essential Guide to Doing Your Research Project. 3rd ed. Sage Publications Ltd; 2017. ISBN: 9781529690200
    62. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. Jan 2006;3(2):77-101. [CrossRef]
    63. Greenfield D, Moldovan M, Westbrook M, et al. An empirical test of short notice surveys in two accreditation programmes. Int J Qual Health Care. Feb 2012;24(1):65-71. [CrossRef] [Medline]

    ‎
    A-HSOPS 2.0: Australian Hospital Survey on Patient Safety Culture (version 2.0)
    AHSSQAS: Australian Health Service Safety and Quality Accreditation Scheme
    GRAMMS: Good Reporting of A Mixed Methods Study
    HSO: health service organization

    Edited by Javad Sarvestan; submitted 05.May.2025; peer-reviewed by David Greenfield, Mohammad Al Zoubi; final revised version received 24.Jan.2026; accepted 29.Jan.2026; published 22.Apr.2026.

    Copyright

    © Robyn Scanlan, Tracy Flenady, Amy-Louise Byrne, Jenni Judd. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 22.Apr.2026.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.