Tissue committee

(a) The tissue committee (or its equivalent) shall review and evaluate all surgery performed in the hospital on the basis of agreement or disagreement among the pre-operative, post-operative, and pathological diagnoses, and on the acceptability of the procedure undertaken. Reviews may be conducted by hospital staff or conducted as a part of the quality improvement program. All reviews shall be conducted based on criteria established by the committee. (b) The committee shall be available to meet as often as necessary and shall submit a written report to the executive committee. (c) This committee's work shall include continuing education through such mechanisms as utilization of its findings in the form of hypothetical cases or review of cases by category at staff meetings or publishing in coded form physicians' standings in the hospital regarding percentage of cases in which normal tissue is removed.