{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T19:31:38Z","timestamp":1793302298421,"version":"4.5.0"},"reference-count":28,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T00:00:00Z","timestamp":1790121600000},"content-version":"vor","delay-in-days":1,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,5]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>External quality frameworks such as ISO 9001 certification lay the foundation for healthcare quality, patient safety, and operational efficiency, but sustained improvement depends on leadership, a culture of safety, and systems that translate assurance into ongoing learning. Evidence on this transition from low- and middle-income countries, particularly in specialized cardiac care, remains limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective longitudinal analysis of quality assurance data from January 2020 to December 2025 was conducted at the Peshawar Institute of Cardiology (PIC-MTI), Pakistan. Independent-samples t-tests, one-way ANOVA, and Difference-in-Differences (DiD) modeling were applied, with three regional hospitals of similar bed capacity and patient volume serving as a comparison group.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Following ISO 9001 certification (February 2022), monthly mortality within 48\u2009h declined from 2.8% (SD \u00b1\u20090.4%) to 1.9% (SD \u00b1\u20090.3%) (t\u2009=\u20093.21, df = 58, P\u2009=\u2009.004). Hospital-acquired infections (HAIs) fell from 3.2% to 2.0% (t\u2009=\u20094.15, P\u2009=\u2009.002), reaching 1.3% by 2025, with zero CLABSIs recorded in the final quarter following the mid-period intensification of the infection-control bundle. Mean length of stay decreased from 6.2 to 4.7\u2009days [ANOVA: F(2,57)\u2009=\u20098.76, P\u2009&amp;lt;\u2009.001]. Patient satisfaction rose from 78% to above 90%. DiD modeling found a net 30% reduction in HAIs and 20% reduction in length of stay (LOS) associated with the certification process relative to the comparison trajectory.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>ISO 9001 certification, undertaken alongside deliberate investment in leadership, a culture of safety, and structured use of data, is associated with sustained improvements in clinical outcomes and operational efficiency at a resource-limited cardiac care center that has not yet pursued formal Joint Commission International (JCI) accreditation but is using JCI\u2019s standards, as one example of an internationally recognized framework, to guide its preparation. The pattern observed here suggests that a learning quality management system, and not any single certificate or accreditation status, is what converts external standards into measurable gains, offering a replicable model for institutions considering how to move from quality assurance toward continual quality improvement.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/intqhc\/mzag154","type":"journal-article","created":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T11:14:23Z","timestamp":1789989263000},"source":"Crossref","is-referenced-by-count":0,"title":["ISO 9001 and JCI preparedness as drivers of quality improvement at a tertiary cardiac care center: a 5-year analysis from Pakistan"],"prefix":"10.1093","volume":"38","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5531-4400","authenticated-orcid":false,"given":"Huma","family":"Shakoor","sequence":"first","affiliation":[{"name":"Health Safety & Environment, Peshawar Institute of Cardiology , Peshawar,","place":["Pakistan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-4556-1995","authenticated-orcid":false,"given":"Waqas","family":"Naseem","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, University of Debrecen , Debrecen,","place":["Hungary"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Syed Shahkar","family":"Ahmed Shah","sequence":"additional","affiliation":[{"name":"Cardiac Surgery, Peshawar Institute of Cardiology , Peshawar,","place":["Pakistan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naveed","family":"Shah","sequence":"additional","affiliation":[{"name":"Quality Assurance Department, Peshawar Institute of Cardiology , Peshawar,","place":["Pakistan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdul","family":"Karim","sequence":"additional","affiliation":[{"name":"Quality Assurance Department, Peshawar Institute of Cardiology , 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