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.

The research objectives are as follows:

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).

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.

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.

(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].

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 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 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.

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).

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.

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.

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.