December 19, 2012 | | Comments 2
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And who do you think gave you permission to do that, mister man?

One of the interesting dynamics that can come into play relative to code compliance is the concept of getting permission for this, that, or the other thing, from our old friend the Authority Having Jurisdiction (AHJ).

For instance, there are probably a number of you who work in facilities of a certain vintage that indicated the installation of “occupant hoses”—you know, those canvas-y things that used to be coiled up in lovely cabinets. And many, if not most, of you who had such hoses were able to get the permission of the local fire folks to remove them. I mean, really—you’re not going to use them, your staff is not going to use them, and the fire department sure isn’t going to use them, so it’s not a difficult thing to imagine. In some instances, you may have to wait until your facility is fully sprinkled, but generally you can get the locals to sign off on it.

Likewise, you may have a fire pump that, for whatever reason, can’t undergo the annual test at a flow of 150% of the rating for the fire pump. Or you may have a medical gas system component that is not quite up to code, but is allowed by the AHJ as long as you agree to correct the condition when you renovate the applicable space. A common condition is the placement of medical gas zone shutoff valves in the same space as the outlets being controlled—no intervening wall to separate the valve from the outlet (I see this a lot in PACU’s of a certain vintage) and the condition poses no significant risk to occupants, etc. These are both examples of conditions that you wouldn’t have to fix as long as you had the permission of the AHJ.

So, you might ask, what’s the point of this? Well, an interesting phenomenon has been popping up periodically this survey year and it revolves around reliance on the permission of the local AHJ to defer correction of certain items like those noted above. And the sticking point is this – if you have not, upon receipt of this “permission” from the AHJ, then submitted that permission to TJC as a request for a traditional equivalency (you can submit the request on-line through the e-SOC portal – I think you’re going to find you’re using this portal more and more frequently in the future).

To be honest, the process of submitting equivalency requests with TJC has long been in the mix, but it appears that it is becoming a focus in survey year 2012. So, if you’ve been given permission from your AHJ for whatever little condition it might be, you better make sure you’ve submitted the equivalency request to TJC. I have no reason to think that these requests wouldn’t be approved, so long as they are reasonable (i.e.,not indicative of a significant risk). After all, I think one of the key elements in the relationships we have with the folks in Chicago is to let them know what’s going on in an open and forthright manner. I suspect it’s what we would all want if the roles were reversed.

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Filed Under: Life Safety Code


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

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  1. When the thing you got permission to do results in an adverse event, do you really want to be stuck with the argument that we knew it was a deviation but XYZ said it was ok? Does permission transfer responsibility, or does it just create a record that you knew you were doing something wrong, and intended to do it wrong on an ongoing basis?

  2. William– Steve Mac responds:

    Ah – and there’s the rub. It ultimately “defaults” to what we, as safety professionals, bring to the table as our best judgment.

    Just as many regulatory requirements are merely a starting point when it comes to the activities of compliance Good example: the TJC requirement for safety rounds to be conducted twice a year in areas where patients receive treatment, care, services, etc. Is two times per year enough oversight to ensure compliance?

    A big part of our responsibility is to “make the call,” and with that comes enormous potential for making the wrong decision. I like to think that we’ve gotten to where we are by making good decisions/choices when it comes to managing risks in the physical environment. But neither are we omniscient, omnipotent, omnipresent, or omni-awesome (well, maybe the last one). So we have to rely on others to be reasonably prudent, etc. in how they conduct themselves and for us to be there to catch them when they fall (and fall they will, but hopefully not too often or hard).

    Happy Solstice to all and to all a good…

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