Cleveland Clinic provides twenty-four hour inpatient pharmacy services through central and specialty pharmacies. Inpatient pharmacy areas support distributive and clinical pharmacy services provided by staff pharmacists, clinical pharmacy specialists and pharmacy technicians, and are provided by 82 FTE pharmacists and 125 FTE technicians. The inpatient pharmacy services over 60 nursing units, 70 operating rooms, four PACUs, and 10 cath labs, accounting for over 1,300 inpatient beds.
The majority of inpatient pharmacy services are delivered from the Central Pharmacy located in the basement of the H building. Remaining services are delivered from the specialty pharmacies which include the ICU pharmacy, the Sydell and Arnold Miller Family Heart & Vascular Institute Pharmacy, and the Children’s Hospital Pharmacy.
The inpatient pharmacy provides around-the-clock services including medication receipt, storage, repackaging, dispensing, distribution, controlled substance services, 24-hour unit dose cart fills, sterile product preparation, specialty compounding, drug information, drug interaction and allergy screening, and monitoring of drug therapy.
Physician orders are received in the pharmacy mostly via Computerized Physician Order Entry (CPOE), while delivery of medications is accomplished through the use of our Pyxis Direct system, technical staff rounds or via the pneumatic tube system. Pyxis Direct allows nursing access to medications via automated dispensing systems located on each floor immediately after pharmacist order review and verification.
The Central Pharmacy directly services 30 inpatient nursing units covering over 700 patient beds, processes on an average 3,800 orders per day and also supports the operations of the specialized pharmacies, which include an intensive care pharmacy, a children’s hospital pharmacy and an oncology pharmacy. The central pharmacy also provides support for post acute services, on-campus clinics and family health centers.
Sterile Products and Compounding»
Sterile Products and Compounding provides services of intravenous (IV) medication admixture, chemotherapy medication preparation, and extemporaneous compounding of pharmaceutical preparations.
All sterile compounding within the central pharmacy is performed in a state-of-the-art, open architecture clean room setting, and strict guidelines are adhered to with regards to compounding practices to meet USP 797. The central pharmacy clean room produces an average of 1,400 products per day.
In 2008 the pharmacy expanded the batch compounding area to ensure levels of frequently used compounded intravenous medications are readily available and are tested for sterility. This area produces over 50 line items that accounts for 4,500 products compounded per week.
The pharmacy currently outsources the production of cardioplegia solutions and Total Parenteral Nutrition (TPN) to Central Admixture Pharmacy Services (CAPS). CAPS pharmacies operate 365 days a year to compound, dispense and deliver labeled, patient-specific IV prescriptions.
Controlled Drug Services»
The controlled drug service has the responsibility to carry out processes for the selection, procurement, receipt, storage, distribution, security, control, and accountability of controlled substances within the CCF Hospital, Outpatient Clinics, and Laboratories. This ensures that the pharmacy is in compliance with all laws and regulation of The Ohio Board of Pharmacy and Drug Enforcement Administration.
The control drug service loads 150 new control medications to automated dispensing units per week and refills 2,800 line items per week, which accounts for 42,600 dispenses per week.
The intensive care unit (ICU) pharmacy is located on the 5th floor between the H and G buildings. This pharmacy provides first dose intravenous medications to the ICUs located in both buildings.
Orders are received via CPOE and medications are delivered by the technical staff. The ICU pharmacy supports 11 nursing units and 135 patient beds, and processes an average of 700 orders per day.
Sydell and Arnold Miller Family Heart & Vascular Institute Pharmacy»
The Miller Family Heart & Vascular Institute Pharmacy primarily services the Miller Family Pavilion and the Glickman Tower. It is a stand-alone pharmacy that provides medication distribution, drug information, drug interaction and allergy screening, and monitoring of drug therapy to patients in these areas. Orders are received through CPOE and delivery of medications is accomplished through the use of our Pyxis Direct system, technical staff rounds or via the pneumatic tube system.
The Miller Family Heart & Vascular Institute Pharmacy supports 278 patient beds in 22 nursing units, 14 operating rooms and 10 cath labs, on average processing 1,200 orders per day.
Cleveland Clinic Children's Pharmacy»
The Children’s Hospital pharmacy, located on the Pediatric Cardiology Unit, operates seven days a week from 7 a.m. - 11 p.m. (10 p.m. weekends and holidays).
The children’s hospital pharmacy supports 11 nursing units and 135 patient beds and ensures that all pediatric patients’ orders are reviewed by pharmacists trained specifically in pediatrics. The Children’s Hospital pharmacy staff completes a 24 hour cart fill for all pediatric patients including unit dosing over 300 oral syringes per day. On average the Children’s Hospital pharmacy processes 360 orders per day.
Nursing Unit-Based Pharmacists Practice Model»
This practice model was developed to expand on clinical pharmacy services provided to hospitalized patients through utilization of nursing unit-based pharmacists. These pharmacists act to bridge the gap between the staff pharmacists (in specialty pharmacies and central pharmacies) and the specialized role of advanced Pharmaceutical Care Specialists, who provide Pharmacotherapy Services. Nursing unit-based pharmacists work closely with Pharmaceutical Care Specialists to extend pharmaceutical care services and address the drug-related problems of hospitalized patients while maintaining liaison relationships with the respective satellite pharmacist(s).
Nursing Unit-Based Pharmacists (NUPB) current areas of practice now include Internal Medicine, Cardiothoracic Intensive Care, Post Acute Services and General Surgery.
The Department of Pharmacy provides care for the diverse needs of more than 400,000 ambulatory patients accessing Cleveland Clinic’s 10 ambulatory pharmacies each year. In addition, this management team provides support to nearly 500 individual physician offices & clinics located in our 10 family health centers, 5 ambulatory surgery centers, 7 regional oncology infusion areas, the Taussig Cancer Institute pharmacy, Crile infusion pharmacy and the Mellen – Post Acute Care pharmacy satellite.
Durable Medical Equipment»
The DME services program started in 2007 and is a service offering within all 10 Cleveland Clinic Pharmacies. This team receives referrals from multiple medical and surgical providers to best meet the durable medical equipment and supply needs of patients being discharged. The DME team also partners with CCHS Managed Care to contract with local, state, and national payers to ensure access for most patients. Annual sales grew to near $200,000 with most activity on the hospital’s main campus.
Pharmaceutical Patient Assistance Program»
The PPAP support area is dedicated to assisting patients and providers obtain financial assistance or access to free prescription medications. The team collaborates with a host of service areas throughout the health system, most notably the Minority Men’s Health Clinic and the Social Services Department. PPAP support includes free consultation; limited free drug voucher and co-pay assistance programs; and fund identification through local, state, and national organizations, both private and public.
The Cleveland Clinic Pharmacies in collaboration with various pharmaceutical companies are offering free trial medication vouchers. Each voucher is obtainable electronically on the department’s intranet website by the patient’s physician, in lieu of actual samples. The single-use vouchers are then presented to any Cleveland Clinic Pharmacy, accompanied by a valid signed prescription from the prescriber and dispensed free of charge to the patient.
Health System Services (HSS) Support»
The Health System Services (HSS) support area is an ambulatory team that provides pharmacy-related operational and clinical support to nearly 500 patient care areas, including the main campus outpatient clinics and procedure areas, the Family Health Centers and other off-site practice locations.
HSS assists with State and DEA licensure while supporting organizational accreditation and compliance processes through routine readiness surveys. This team also supports the safe and effective use of medications in ambulatory areas by implementing novel pharmacy solutions as well as staffing within the five regional ambulatory surgical center’s (ASC) and seven oncology satellites.
The team performed more than 1,500 patient care area inspections, supported more than 26,000 surgical cases within the regional ASCs and compounded more than 30,000 patient specific chemotherapeutic doses in the regional medical practices sites throughout Northeast Ohio.
Ambulatory Infusion Pharmacies»
The Taussig Cancer Institute Pharmacy services the outpatient and inpatient care needs of the Cancer Center. This team is comprised of dedicated, expert pharmacists, clinical specialists, and technicians all focused on appropriate chemotherapy care. The pharmacists are heavily involved in both the review and oversight of all standard chemotherapy and investigative agents used in more than 180 clinical trials. The clinical staff provides direct support to the pediatric hematology oncology service, the leukemia and lymphoma service, and the bone marrow transplant team. The pharmacy compounds more than 50,000 patient specific chemotherapy doses annually and follows each oncology admission very closely.
The Crile Infusion pharmacy satellite is designed to meet the growing needs of our physician office areas that infuse specialty IV medications to patients. This pharmacy team provides direct support and IV medications to multiple institutes with primary emphasis on rheumatology, ophthalmology, and allergy and immunology patients producing tens of thousands of patient-specific medication orders.
The Mellen-Post Acute Care unit pharmacy satellite serves to support both the ambulatory infusion center in the Multiple Sclerosis area and Center for Rehabilitation. Activities include preparing IV medications, order review and restocking functions, and completing the Federal and State required Medication Regimen Reviews (MRR’s). After hours support for both the Crile and Mellen satellite pharmacies are provided by the inpatient pharmacy.
Pharmaceutical Care Clinic»
The PCC was established as a pharmacy-based outpatient clinic to provide medication management. Presently the vast majority of PCC patients are seen for anticoagulation management.
The PCC provides high-quality patient education and anticoagulant management which results in optimal patient outcomes. Care is provided under an institutional consult agreement. Per referral policy, patients must be referred by CC physicians.
Services are offered on main campus and the Beachwood, Westlake, Lorain, and Solon Family Health Centers. Patients can also be referred to our pharmacists for diabetes, lipid, hypertension and general medication management.
Acute Care Services
Pharmacotherapy Specialists provide clinical pharmacy knowledge and experience to specific medical/surgical services throughout the medical center. These acute care specialists are pharmacists with Doctor of Pharmacy degrees and most have specialized residency training. By working directly with physicians and patients, these specialists serve as experts for optimizing drug therapy.
In additional to direct patient care activities with the medical staff, these individuals provide education on the appropriate use of medication to physicians, nurses, students, and other health professionals and are responsible for research in their respective areas. They also have responsibility for therapeutic guideline development, program development in drug monitoring, educating pharmacy residents, and teaching in the Cleveland Clinic Lerner College of Medicine and the Ohio College of Podiatric Medicine. Some of these individuals have teaching responsibilities at local nursing schools. Several acute care specialists have administration responsibilities including residency and student programs, Nursing Unit Base Pharmacist (NUBP) practice model development and implementation and personnel management.
Pharmacotherapy Services Acute Care Practice Areas
- Bone Marrow Transplant
- Cardiovascular ICU
- Coronary Care Unit
- Heart Failure ICU
- Heart Transplant
- Infectious Diseases
- Internal Medicine
- Liver Transplant
- Lung Transplant
- Medical ICU
- Neonatal ICU
- Nephrology and Kidney Transplant
- Neurology/Neurosurgery ICU
- Pediatric ICU
- Pediatric Oncology
- Surgical ICU
Pharmacists documented more than 41,000 interventions with a direct cost savings of $286,000 and a cost avoidance of $1.5 million.
Drug Information Center
The Cleveland Clinic Department of Pharmacy Drug Information (DI) Center is a reliable source of objective drug information on medication and medication-related topics. The services of the DI Center are available to health care professionals from CC and CCHS. The DI Center is also responsible for the Formulary and Drug Therapy Guide, Pharmacotherapy Update Newsletter, Adverse Drug Reaction (ADR) Monitoring and Reporting, and the Adult IV Medication Guidelines. Additionally, the Center coordinates all of the Formulary Specialty Panel and Pharmacy and Therapeutics Committee meetings, minutes, and implementation of decisions.
The Cleveland Clinic Pharmacy and Therapeutics Committee consists of the parent committee, six specialty panels (SP) (Cardiovascular/Thrombosis, Neurosciences, Hematology/Oncology, Critical Care/Surgery/Anesthesia, Transplant, Antimicrobial Review) and two Sub-Committees (Pediatrics and Medication Systems). The SPs are responsible for evaluating formulary requests, developing guidelines and restrictions, reviewing cost/utilization issues, adverse drug reaction monitoring, and developing/reviewing outcomes projects and drug use evaluations. Each SP meets quarterly, chaired by a member of the medical staff along with a “Lead Clinical Pharmacy Specialist” serving as Secretary. The SP structure has provided a heightened awareness by physician members of formulary issues including medication safety and costs which results in insightful recommendations to the P&T.
Medication Safety Services coordinates a comprehensive program dedicated to assuring excellence in medication safety and quality. Medication Safety Services facilitates the continuous evaluation of the medication management system to implement strategies that reflect medication safety best practices and mitigate or eliminate actual and potential system vulnerabilities. Medication Safety Services also ensures compliance with all applicable accreditation and regulatory standards.
Medication Safety Services staff are responsible for the review, collation and analysis of all medication related events. The staff provides continual follow-up and monitoring of interventions and medication error trends ensuring that all medication related events are categorized and recorded into the appropriate databases. Medication Safety Services staff is also responsible for reporting significant medication safety findings and trends to the Medication Systems Subcommittee, Pharmacy and Therapeutics Committee, the Patient Safety Committee and Department of Pharmacy Quality Council.
Medication Safety Services staff also play an integral role in identifying and defining priorities for quality improvement activities. This includes structuring and coordinating planned interventions to correct procedural deficiencies and to enhance or implement safety systems. Medication Safety Services staff assists with assuring appropriate follow-up and system application of specific process improvements related to internal and external improvement concepts. The staff also identifies and assists with stock and formulary medication safety related improvement processes.
Additionally, Medication Safety Services ensures timely communication of regulatory/accreditation issues to appropriate parties. The staff also assists with collection and consolidation of accreditation/regulatory compliance data and assists internal accreditation teams.
Pharmacy Services assumes responsibility for the development and implementation of tactical and strategically focused recruiting programs for the professional and technical staff throughout the Cleveland Clinic Health System. This service provides overall management of the recruitment processes and systems employed to respond to organizational needs. Establishing and planning programs and activities to effectively coordinate, manage and provide leadership of the overall staffing function system wide is part of our responsibility. Working with management to ensure timely understanding of current and future workforce needs along with implementing improvements to staffing processes helps us to become more effective. Develop and implement effective recruitment and hiring procedures and practices that will result in attracting and retaining the highest qualified candidates.
Cleveland Clinic Pharmacies has a dedicated group of personnel that provide Clinical Informatics, Automation, and Information Systems support.
The Informatics team provides system build, system maintenance, and troubleshooting support for the EpicRx system across the Cleveland Clinic Health System, which encompasses 10 community hospitals and the Cleveland Clinic Florida site in addition to the main campus location. They work closely with the Information Technology division on all MyPractice Epic projects whenever medications or pharmacy is involved.
The Automation team supports the implementation, training, and troubleshooting of both the centralized and decentralized automated dispensing technologies. All computers, printers, and interfaces between our systems, web-designed applications, and Sharepoint sites are created and maintained by the Pharmacy Information Systems group.
Over 7,000,000 medication doses are removed from the decentralized cabinets annually by physician and nursing personnel. Over 32 Pharmacy interfaces are maintained in order to route data appropriately for inpatient and outpatient systems.
Pharmacy Contracting and Purchasing
The Pharmacy Contracting and Purchasing service area reports to Cleveland Clinic’s Supply Chain Management department, but closely supports pharmacy operations and financial reporting throughout the health system. The Purchasing and Contracting team is responsible for pharmaceutical contract negotiation and maintenance. The team also coordinates pharmacy’s cost savings improvement and physical inventory processes. Additionally, the team is responsible for replenishment buying and pharmaceutical requisition fulfillment for main campus and the FHC accounts.
Finance, Billing & Reimbursement
On average, each month, Pharmacy produces almost 750,000 of technical charges totaling $40 million which flow through CC billing systems for Inpatient and Hospital Outpatient Services. Pharmacy processes 35-40% of all technical charges at Cleveland Clinic totaling 10% of technical gross revenue dollars. Billing and reimbursement supports all Pharmacy Inpatient and Outpatient Services, and is responsible for timely and accurate charge entry, error tank maintenance, chargemaster and coding updates, denial management, inter-departmental cost transfers, customer service and drug pricing inquiries.
For all of the Cleveland Clinic outpatient pharmacies, we support all revenue cycle functions from insurance pre-certification, decentralized pharmacy billing services, through accounts receivables collections.