For ambulatory care, surgery centres and health systems in the United States
Joint Commission documentation software, built to help you achieve accreditation.
wai runs booking, clinical notes, consent, referrals, follow-ups in any language, billing and reporting for US practices, surgery centres and health systems. Every visit leaves a signed, timed record a surveyor can trace from first enquiry to last follow-up, built to help you achieve accreditation.
How Joint Commission accredits ambulatory care in 2026
Ambulatory organisations are surveyed against the Comprehensive Accreditation Manual for Ambulatory Care. Its National Patient Safety Goals are checked on every survey.
5 safety areas and 9 requirements under the National Patient Safety Goals chapter for the Ambulatory Health Care Program, effective January 2026. Open a safety area for its requirements.1
01Goal 1, patient identificationImprove the accuracy of patient identification.1 requirements
NPSG.01.01.01 Use at least two patient identifiers when providing care, treatment, or services.
02Goal 3, medication safetyImprove the safety of using medications.3 requirements
NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
NPSG.03.06.01 Maintain and communicate accurate patient medication information.
03Goal 7, health care associated infectionsReduce the risk of health care-associated infections.1 requirements
NPSG.07.01.01 Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the current World Health Organization (WHO) hand hygiene guidelines.
Most survey time is spent at the point of care, following patients through the organisation.2
01
Individual tracers
A surveyor reviews a patient's record with the staff member responsible, then traces the care from entry to the end of the episode. Most survey activity happens here.
02
System tracer, data management
How the organisation collects, checks and uses data, including National Patient Safety Goal data and incident reporting.
03
Program-specific tracer, continuity of care
For medical organisations, how a diagnostic test is followed from the order to the patient, and how missed follow-up is prevented.
04
Competence assessment and credentialing and privileging
Orientation, competency and how privileges are granted, checked against staff and credentials files.
05
The survey document list
Performance improvement data, infection control data and plans, the organisation chart, sites, contracts and the day's schedules.
06
Leadership and the exit conference
Leaders discuss the findings, and the surveyor reviews the Summary of Survey Findings and the SAFER Matrix with the organisation.
How Joint Commission reaches an accreditation decision
Joint Commission makes the decision after the post-survey work, including any Evidence of Standards Compliance.3
AccreditationIn compliance at survey, or every RFI resolved through an accepted ESC
Accreditation with Follow-up SurveyIn compliance through an ESC, with a follow-up survey within six months
Limited Temporary AccreditationUnder the Early Survey Policy, after the first of two surveys
Preliminary Denial of AccreditationSubject to review and appeal
Denial of AccreditationAll review and appeal exhausted
60 days
to submit Evidence of Standards Compliance for each Requirement for Improvement, after the final report is posted.4
30 to 36
months between unannounced full surveys, for most programs. Accreditation is valid for about three years.5
3 by 3
SAFER Matrix, plotting each finding by likelihood of harm and by scope, limited, pattern or widespread.6
Compliance is scored against elements of performance. An element of performance out of compliance is cited as a Requirement for Improvement.
Each Requirement for Improvement is placed on the SAFER Matrix by the likelihood of harm, low, moderate or high, and by how widespread it was.
Higher-risk findings need more in the Evidence of Standards Compliance, including leadership involvement and a preventive analysis.
Once the evidence is accepted, the decision takes effect from the last day of the survey.
What Accreditation 360 changes, and for which programs
Hospitals and critical access hospitals moved to a rewritten manual on 1 January 2026. Ambulatory care kept its National Patient Safety Goals.
Joint Commission announced Accreditation 360 in June 2025 and is rolling it out first to the Hospital and Critical Access Hospital programs in 2026.
For those two programs, 14 National Performance Goals replaced the National Patient Safety Goals on 1 January 2026, and the hospital program removed more than 700 requirements.7
Ambulatory Health Care and Office-Based Surgery keep a National Patient Safety Goals chapter, effective January 2026. Joint Commission says work on its other programs has started, with dates not yet set.
Public, searchable standards for every accreditation program are part of Accreditation 360 and open to anyone today.
The chapters of the Comprehensive Accreditation Manual for Ambulatory Care
The 2026 manual sets out 16 chapters of accreditation requirements, named here as Joint Commission names them.8
Chapter
Code
Accreditation Participation Requirements
APR
Environment of Care
EC
Emergency Management
EM
Human Resources
HR
Infection Prevention and Control
IC
Information Management
IM
Leadership
LD
Life Safety
LS
Medication Management
MM
National Patient Safety Goals
NPSG
Provision of Care, Treatment, and Services
PC
Performance Improvement
PI
Record of Care, Treatment, and Services
RC
Rights and Responsibilities of the Individual
RI
Transplant Safety
TS
Waived Testing
WT
Where CMS conditions apply
Joint Commission accreditation sits beside federal rules. These are the ones that reach a private ambulatory organisation.
An ambulatory surgical center paid by Medicare must meet the Conditions for Coverage in 42 CFR Part 416, including governing body, surgical services, medical records, patient rights, infection control and patient admission, assessment and discharge.9
CMS may deem an ASC compliant when a national accrediting body it approves accredits it. Otherwise the state survey agency surveys it. Joint Commission is a CMS-approved accreditor for ASCs, and CMS makes the final Medicare certification decision (Joint Commission, CMS).
Laboratory testing on people for diagnosis, prevention or treatment falls under CLIA, and a laboratory must be certified to be paid by Medicare or Medicaid.
HIPAA applies to covered entities. In the US, wai acts as a business associate and signs a business associate agreement before any encounter. HIPAA readiness also depends on your own role, agreements and controls (AI scribes and HIPAA).
State health departments and medical boards in our US cities
States license clinics, surgical centres and office-based surgery in different ways. What each state's own pages say, for the cities we serve.
Office-based surgery under Public Health Law 230-d, in an accredited setting, with adverse events reported to the Department of Health within three business days of the occurrence of the event.
Los Angeles, San Diego, The Bay Area, Montecito and Santa Barbara, Pebble Beach and Carmel-by-the-Sea
CDPH licenses surgical clinics, with physician-owned offices excluded. Settings using anesthesia beyond local must be accredited, licensed or certified.
Miami, Fort Lauderdale, Boca Raton, West Palm Beach, Naples, Tampa and Sarasota
Health care clinic licences under the Health Care Clinic Act, with exemptions. Offices doing Level II or III surgery register, and are inspected yearly unless accredited.
What Joint Commission accreditation software should run
Booking, notes, consent, messaging, billing, access and reporting on one record, the same record a surveyor traces.
01
Appointments and booking
Online booking from your own website, every clinician's diary read from their calendar, reminders, rebooking after a missed visit and waitlist offers when a slot opens.
Online booking at any hour, with a reminder before the visit.
For the business
Fewer missed appointments, and cancelled slots offered to the waitlist.
On the record
Every booking, reminder and change, with a time and a name.
02
Billing and payments
Card payments into your own Stripe account, the cancellation policy shown at booking, invoices, statements and reconciliation, with an export for your accountant.
A clear price and policy before they commit, and an invoice in their app.
For the business
Payments reconciled against visits, with an export for your accountant.
On the record
The price and cancellation policy the patient saw before booking, against the visit it was charged for.
03
AI scribe and clinical notes
The note, letters and referrals written from the consultation, cited to current guidance and peer reviewed research, with the transcript beside the note, for the clinician to read, edit and sign.
The clinician's attention stays on them during the consultation.
For the business
Less time spent writing notes after clinic.
On the record
A contemporaneous note, signed, with the time, the signature and the source it cites.
04
Follow-ups and patient messaging
WhatsApp, email and calls in one thread per patient, replies drafted in the patient's own language for your team to approve, a response clock on every new enquiry, and recalls a clinician approves.
A reply in the language they wrote in, approved by your team.
For the business
More enquiries answered within the hour, when they are most likely to book.
On the record
The whole conversation on one record, with response times.
05
Referrals, consent and audit trails
Recording consent taken at booking, referrals written from the visit, patient flags for controlled drugs and safeguarding notes, and every read of a record logged against a named account.
How does wai evidence each Joint Commission safety area?
For each safety area, the records wai keeps, how you produce them, and what changes for patients and the business.
Goal 1, patient identification
One record per patient carries the same details from booking to the last letter.
The patient's details from booking carried onto every note, letter, referral and message
One thread per patient for WhatsApp, email and calls
Every read and change of a record logged against a named account
On request. Open any patient. The booking, notes, letters and messages sit on the same record.
For patients
Nobody asks them to repeat who they are at every step.
For the business
Fewer wrong-patient corrections to find and fix.
Goal 3, medication safety
The medicines discussed in the visit are in the signed note, and the patient leaves with them in writing.
Notes written from the consultation, with the medicines discussed, for the clinician to check and sign
Letters to the patient and their other doctors written from the visit
Patient flags for controlled drugs
Replies drafted in the patient's own language, approved by your team
On request. Show what the patient was taking, what changed and what they were told, from the note and the letter.
For patients
A clear written list of what to take, in a language they read.
For the business
Reconciliation done in the visit instead of in a callback.
Goal 7, health care associated infections
Hand hygiene stays with your infection prevention lead. Time spent typing goes back to clinical work.
Notes drafted during the visit, so clinicians are not typing between patients
Every visit, procedure and clinician on the record, for the infection control data your lead keeps
Messages to patients before a visit, sent from the same thread
On request. Pull the visits and clinicians for any date range to sit beside your surveillance data.
For patients
More of each visit spent with the patient.
For the business
Infection control data that starts from an accurate list of visits.
Goal 16, health outcomes for all
Patients are answered in their own language, and the data for your disparity work can be exported.
Replies drafted in the language the patient writes in, approved by your team
Online booking at any hour, reminders and rebooking after a missed visit
Front desk, response and website reports, and each patient's record exportable on request
On request. Show response times and attendance for the population your action plan targets.
For patients
Care they can reach and understand, in their own language.
For the business
Fewer missed visits and a measure to report against your goal.
Universal Protocol
The consultation that led to the procedure is signed, timed and on the record before the patient arrives.
The consent discussion in the clinician's signed note
Referrals and letters written from the visit
Every read and change of the record, against a named account
On request. Show the note, the consent discussion and the referral for any procedure, with their times.
For patients
The same plan, understood the same way, by everyone in the room.
For the business
Preprocedure verification that starts from a complete record.
Patient and business outcomes, from published research
Three published figures on response times, documentation time and attendance.
7x
An enquiry answered within the hour is nearly seven times as likely to become a real conversation.10
30%
Clinicians using an ambient scribe did 30% less work after hours.11
23%
Patients sent a notification before their visit were 23% more likely to attend.12
How wai produces the records a surveyor asks for
What a tracer asks for, where it lives in the system, and how it is produced.
Asked forWhere it livesHow it is produced
The record of a traced patientThe patient record, beside the transcriptOpen the visit. Signed note, transcript, letters and referrals appear together, with times.
Two patient identifiersBooking and the patient recordThe details taken at booking, carried onto every note, letter and message on that record.
Medication informationThe signed note and the patient's letterThe medicines discussed in the visit, and the written information the patient left with.
The consent discussionThe signed noteWhat the patient was told and agreed, in the clinician's own signed words.
Test and referral follow-upReferrals and the patient's threadThe referral letter written from the visit and every follow-up message, on one record.
Access and changesEvery recordWho read or changed it, under which account, to the minute.
Credentials and privilegesYour own credentials files, with accounts and roles in the systemYour files hold licences and privileges. wai shows the role each person held and every note each clinician signed.
Performance improvement dataReportsFront desk, response, takings and website reports, exportable for the measures your team tracks.
Patient rights and price informationBooking and the patient appThe cancellation policy and price the patient saw before they booked.
Joint Commission ambulatory care checklist
Grouped the way the survey runs, from the document list to Evidence of Standards Compliance.
01The survey document list
Performance and quality improvement data from the past 12 months.
Infection control plan and 12 months of surveillance data.
Organisation chart, list of sites and locations, and list of contracted services.
Appointment or surgery schedules for each day of the survey.
Your most recent culture of safety and quality evaluation.
02The record of care
Notes signed and complete for every visit in the last month.
Two identifiers used on every record, label and specimen.
A medication list taken at the start of the episode and given to the patient at the end.
Diagnostic tests followed from the order to the patient, with a named owner.
03National Patient Safety Goals
Medication labelling in procedural settings, checked on a live procedure.
Anticoagulation monitoring, if you prescribe it.
Hand hygiene monitored against CDC or WHO guidance.
A named leader and an action plan for health outcomes for all.
Preprocedure verification, site marking and time-out for every invasive procedure.
04People
Credentials files with current licences, training and privileges granted by the governing body.
Competency assessment and orientation records for staff and contracted staff.
A named account for every person in every clinical system.
05After the survey
Read the final Summary of Survey Findings on Joint Commission Connect.
Submit Evidence of Standards Compliance within 60 days for each finding that needs it.
Show leadership involvement and a preventive analysis for higher-risk findings.
What a Joint Commission surveyor asks staff
Questions drawn from the topics in Joint Commission's ambulatory Survey Activity Guide, and where the answer lives.
01Walk me through this patient's care, from the day they first contacted you.
What to show
The record from first contact to the end of the episode, with hand-offs.
Where wai has it ready
The enquiry, booking, signed notes, letters and messages sit on one patient record, in order.
02How do you make sure an abnormal test result is followed up?
What to show
The tracking method and the follow-up for a real patient.
Where wai has it ready
Referrals are written from the visit and every follow-up message sits on the patient's thread.
03Which two identifiers do you use, and where?
What to show
The identifiers on the record, the letter and the label.
Where wai has it ready
The details taken at booking carry onto every note, letter and message on the record.
04What medicines was this patient taking, and what did they leave with?
What to show
The medication list, the comparison and the written information given.
Where wai has it ready
The medicines discussed are in the signed note, and the letter the patient received is on the record.
05How do you protect the confidentiality of the health information you collect?
What to show
Access controls, named accounts and how access is checked.
Where wai has it ready
Role-based access enforced in the database, and every read logged against a named account.
06How do you use data to improve performance?
What to show
A measure, its trend and the project it drove.
Where wai has it ready
Response, front desk and takings reports, read by leaders each week and exportable.
07Who granted this clinician's privileges, and when were they last reappraised?
What to show
The credentials file and the governing body's decision.
Where wai has it ready
Your credentials file holds this. wai shows the account and role the clinician works under and every note they signed.
What a Joint Commission accreditation decision means, and what accreditation costs
The decision is published, it can carry Medicare deemed status for a surgery centre, and Joint Commission bills for it in every year of the three-year cycle.
Public
Once Evidence of Standards Compliance is approved, the accreditation decision is posted to Joint Commission's Quality Check site on the following business day.2
2,200+
organisations hold Joint Commission Ambulatory Health Care accreditation, from surgery centres and imaging to medical group practices and urgent care.13
Medicare
An ASC accredited by a CMS-approved body can be deemed to meet the Conditions for Coverage, and Joint Commission surveys for accreditation and Medicare certification at the same visit.9
3 years
of annual fees across the accreditation cycle, plus on-site fees in the survey year, priced on your services and average daily census.14
What is the best Joint Commission documentation software?
Software your organisation runs on every day, so a surveyor can trace a patient through one record. Look for booking, signed and timed notes, consent, referrals, patient messaging and an audit trail on the same record, with named accounts and roles. wai is built that way, to help you achieve accreditation.
Is there Joint Commission approved software?
Joint Commission accredits health care organizations. It does not approve, certify or endorse software, wai included, and software cannot earn an accreditation decision on a provider's behalf. wai keeps the records your team uses to show Joint Commission how care is delivered, and Joint Commission decides the accreditation decision.
Does Accreditation 360 apply to ambulatory care?
Not yet. Joint Commission rolled Accreditation 360 out to the Hospital and Critical Access Hospital programs first, in 2026, with National Performance Goals replacing the National Patient Safety Goals for those two programs. Ambulatory Health Care and Office-Based Surgery keep the National Patient Safety Goals chapter effective January 2026. Joint Commission says work on the other programs has started, with dates still to be set.
What are the National Patient Safety Goals for ambulatory care in 2026?
Goal 1 covers patient identification, Goal 3 covers medication safety (labelling, anticoagulant therapy and medication information), Goal 7 covers hand hygiene and Goal 16 covers health outcomes for all. The same chapter carries the Universal Protocol for preprocedure verification, site marking and the time-out.
How long do we have to submit Evidence of Standards Compliance?
60 days. The final Summary of Survey Findings report says which findings need an ESC, and the decision follows once Joint Commission accepts it.
How often does Joint Commission survey an ambulatory organisation?
Most surveys are unannounced, 30 to 36 months after the last full survey. Initial surveys that are not for deemed status come with 30 days' notice, and some resurveys, including office-based surgery, come with seven business days' notice.
How does wai handle HIPAA?
In the US, wai acts as a business associate and signs a business associate agreement before any encounter. HIPAA readiness also depends on your own role, agreements and controls.
Where does wai keep our records?
Records hosted in the United States, set up with your organisation. Every read and change is logged against a named account.
Does wai work for hospitals and health systems?
Yes. Every location runs on the same record, inbox and reports. Health systems usually start with one ambulatory pathway, measure it on their own data, and extend it from there.
Fifteen minutes on video, using your own diary, notes and inbox. Built to help you achieve accreditation. Records hosted in the United States, set up with your organisation.
