Tissue Committee of a stetrics, and such other departments as desired-

Hospital Medical Staff usually the Pathologist should sit as a member of

this committee or ex officio. The duties of the Tissue
A Report of the Medical Review Committee shall be to study and report to the staff,
And Advisory Board or to the Executive Committee of the staff, on the
agreement or disagreement among the preoperative,
SERVICE TO HUMANITY is the principal objective of postoperative and pathological diagnoses and on
the medical profession. Physicians, faithful to the whether the surgical procedures undertaken in the
honored traditions of the profession, recognize that hospital were justified or not. This study will also
they are trustees of medical knowledge and skills. include those procedures in which no tissue was re-
The Code of Medical Ethics obliges all members of moved. The report to the Executive Committee shall
the profession to "strive continually to improve med- be in writing on at least a monthly basis."
ical knowledge and skill, and . make available to
. .

their patients and colleagues the benefits of their Purpose of the Tissue Committee
professional attainments." The tissue committee's function is to further med-
American physicians have developed, as an inte- ical staff education and self-discipline. Its influence
gral part of the practice of medicine, the concept should be positive. By analysis and review of tissues
that physicians admitted to privileges in the hospital, removed, continuing education is afforded to elevate
should organize themselves into a self-governing the caliber of medical care being provided in the
medical staff. Good hospital administration today hospital. The work of the tissue committee is not
and the law in many states which regulates hospital directly concerned with a particular patient's medi-
organization, have uniformly adopted this principle. cal problem, or what should be done about it. It is,
The ethical and legal concepts concerning contin- instead, a postsurgical activity, taking place usually
uing education and self-government of the hospital quite some time after the patient has left the hospi-
medical staff, have fostered the orgapization of med- tal, relating to the tissue removed. Study and com-
ical staff review committees. Through the work of parison is made of the preoperative diagnosis with
these committees, the public and professional re- both the postoperative diagnosis and the patholo-
sponsibility of the whole staff, as well as that of each gist's report. It charts and tabulates the facts and
staff member, is promoted by a review and compari- compares the rpsults with its recent periodic reports
son of the medical work of each member of the staff. and with recommendations of other hospitals, when
The right of medical groups, in good faith, to define available, in order that the practice of all can be
and demand certain requirements of its members, improved by such knowledge.
has been upheld by the courts when these require-
ments have a reasonable connection with improving Tissue Committee Method of Procedure
and maintaining the standards under which mem- In general, there are at least three methods of
bers practice their profession, and tend to regulate operation- this committee may use to review the sur-
fair dealing among the members of the profession gical work of the staff or any part of it. First, the
and with the public. medical history itself may be reviewed. A second
There is one medical staff review committee, or and rather simple and direct method is to make pro-
several, concerned with all or different facets of vision for one extra copy of the pathologist's report
medical care rendered in a hospital. Frequently, the to be prepared and sent to the tissue committee,
size of the hospital and the number of records to be identified only by case number. When this system
reviewed determines the number of review commit- is used, the preoperative and postoperative diagnoses
tees needed. This paper will describe the tissue com- must be shown on the pathology report. The third
mittee, its organization, purpose and function when method is to provide for a synopsis worksheet to be
it is separately established. However, some medical prepared by the records librarian which has posted
staffs will have one committee perform this and to it such vital information as:
other functions. The general procedures outlined 1. Patient's hospital number;
here would be applicable in both instances, with 2. Patient's age;
appropriate revisions and modifications.
The Model Medical Staff By-Laws recommended 3. Preoperative diagnosis;
by the Joint Commission on Accreditation of Hos- 4. Postoperative diagnosis;
pitals, suggests the formation of a tissue committee 5. Operative procedure;
in the following language: 6. Tissue removed, if any;
"The Tissue Committee shall include representa- 7. Tissue number;
tives of the departments of surgery, gynecology, ob- 8. Pathological diagnosis, if any; and
Approved by the Council of the California Medical Association, 9. Operative and postoperative complications.
August, 1961.

264 CALIFORNIA MEDICINE

The following is a description of\ the worksheet the patient's number, the number corresponding to
method to illustrate how it operates. Each hospital the final disposition (Arabic numeral 1, 2, or 4), fol-
tissue committee ought to devise its own system, lowed by the date of final disposition. Since these
best suited to itself. The plan that is illustrated is file cards are maintained only for purposes of iden-
used by many and can serve as a guide. In the in- tifying which cases have been reviewed, and in gen-
terest of brevity, alternate plans are not outlined. eral, what percentage of such cases have required
The committee chairman or other designated more than the information contained on the work-
members review each worksheet. Where there is sheet for evaluation, there need be no further com-
consistency throughout, and where no operative or ment. It should be remembered that a difference of
postoperative complications occurred, the results are medical opinion concerning a case need not indi-
merely tabulated for the purpose of interim and cate inadequate care.
annual reports. In those instances of diagnostic and
pathological inconsistency, or occurrences of com- CENTRAL FILE CARD
plications, the case is assigned to a member of the
committee for a more detailed examination. The ex- DOCTOR
tent of further evaluation will include at least a Patient Dispo-
review of the patient's chart, and may include a Number sition Date
personal interview with the attending physician. 3425 1 2/17/60
Not only must this evaluation attempt to resolve 6789 2 2/26/60
reasonably any disagreement among the preopera- 7127 1 3/ 5/60
tive, postoperative, and pathological diagnoses, but 7536 2 3/14/60
7718 4 3/22/60
it should also attempt to determine whether the sur- 7931 1 4/ 4/60
gical procedure performed was adequately indi-
cated, and whether the quality of the work is
acceptable. If a particular case requires corrective action
At the next committee meeting, each member re- concerning the attending physician, a written memo-
ports his findings to the entire committee for ap- randum by the executive committee should be main-
praisal. The results and recommendations are then tained in the physician's credentials committee file.
tabulated as before. Cases presenting unresolved in- In the absence of corrective action, there is no rea-
consistencies or potential deficiencies in desired son to maintain any records in addition to the in-
standards of care, are referred to an appropriate formation ultimately contained on the central file
administrative medical staff committee (herein card as noted above. If at any later date it appears
called the executive committee) for further eval- that a particular doctor is accumulating an excessive
uation. quantity of cases requiring executive committee ex-
At the bottom of each worksheet are four num- amination ("4" on his file card), the various pa-
bered items, each corresponding to the extent of tients' records or microfilms thereof, so identified,
investigation necessary. They are checked and dated can be rereviewed in concert by the executive com-
when completed. mittee to determine the presence or absence of a
Check Date
specific pattern of needed corrections. Self-discipline
1..................... Completed on worksheet. through staff education is promoted.
2.
2. ................... Completed on additional evaluation The Statistical Report of the Tissue Committee
3-.------------- Referred to executive committee.
4- ...---- Completed by executive committee. The format of the periodic and annual report of
this committee can be quite variable, but for proper
The tissue committee chairman checks and dates educational value it should contain both statistics
the appropriate disposition contained within the and comments. An example is as follows:
first three items. All worksheets, regardless of the "The Tissue Committee reviewed 100 operations
type and disposition by the tissue committee, are performed in this hospital during the month of July.
referred to the office of the executive committee for In ninety of these cases, there appeared to be no
sorting and final tabulation. Those cases "referred question about the surgical indication for the re-
to the executive committee" are presented to the moval of the tissue taken. In eight of the remaining
next regularly scheduled meeting of that committee cases, after the clinical record of the patient was
for further evaluation and final disposition. As each reviewed, the committee reached the same conclu-
worksheet is complete in its routing, an indication sion. Two cases were referred to the Executive Com-
of its final disposition is entered on a central file mittee for further review.
card maintained for each staff member of the hospi- "Fifty appendices were removed: Thirty-six were
tal. The items to be entered on this card consist of reported diseased; ten were removed incidental to
VOL. 95, NO. 4 * OCTOBER 1961 26S
other abdominal surgery; three were reported as not cerning the care rendered to a patient. They relate,
acutely diseased, but were justifiably removed on rather, to the process of self-education and self-
clinicosurgical grounds. betterment of the medical staff as a whole.
"Of ten uteri, ovaries, and Fallopian tubes re- Third, the committee records generally are tabu-
moved, eight were reported diseased. The two re- lar and relate to trends. They can be said to be
maining cases revealed justification on clinical strictly confidential intraorganizational studies for
grounds. the purpose of improving medical staff knowledge,
"This record would indicate a considerable im- self-education and self-discipline. Committee mem-
provement over the degree of diagnostic judgment bers' acts and decisions, made in good faith to pro-
since July of last year. Where the clinical record was mote professional standards, are given a qualified
examined, it was found to be in good condition. Im- or limited privilege.
provement could be made, especially in the timeli- Fourth, the standard of judgment used in the
ness and completeness of the record. In one instance, work of the tissue committee is a standard of excel-
an intern entered a conclusion which was not sup- lence. This standard is irrelevant to the issue of the
ported by the facts, and it had not been corrected by prevailing standard of care or diagnostic judgment
the attending physician." used by the ordinary physician in a community.
The Admissibility of Tissue Committee
Records and Testimony of Committee CONCLUSION
Members in Malpractice Suits
The question has frequently been asked, "Can the The multiplicity of modern research achievements
tissue committee records or the members of a tissue and rapidly changing trends are placing an almost
committee be subpoenaed in a malpractice action overwhelming burden on the average medical and
against the attending physician?" Within the knowl- surgical practitioner. Even the most conscientious
edge of the authors, there is no case to date in which finds it increasingly difficult in the face of an active
these issues have been presented and decided by the and demanding practice to read profitably a suffi-
courts. cient number of the better medical journals. Post-
It should be remembered that a subpoena may be graduate courses in various medical centers are
issued for the production of a record or the appear- designed to help the busy practitioner to keep
ance of a witness, but that the record or the testi- abreast of recent developments, but they must neces-
mony might never be admitted in evidence during sarily be limited in subject matter and doctor
the trial of the suit. It would seem that based on exposure.
established principles, tissue committee records or As a matter of fact, any program of continuing
testimony of the members of the committee acting education, whether by articles, courses, seminars or
as a tissue committee, would not be admissible in a the like, will be broadly effective only as far as the
malpractice action. individual practitioner and his local group are ap-
First, there is no physician-patient relationship prised of and carry out the findings and recommen-
existing between the members of the committee and dations of various developments.
the patient. The committee does not examine the pa- To maintain and improve the quality of medical
tient, nor do they consult with the attending physi- care, there is inestimable value in the continuous
cian during the course of treatment. evaluation of current clinical practice and correla-
Second, the records of the tissue committee do not tion of the findings with modern achievements and
become a part of the clinical record of the care ren- trends. The review of tissue and other medical ac-
dered a patient. They are not required as part of tivity can become an integral part of this educa-
the care, are not made contemporaneously with the tional program. A suggested plan for organization
treatment, and do not relate in any way to the treat- and operation of a committee to perform this review
ment. These records are not original records con- is discussed.

266 CALIFORNIA MEDICINE