Well Woman Clinic Concept: An Integrated Approach for Screening and Early Diagnosis of Breast and Gynecological Cancers in Developing Countries

Abstract

A vertical delivery of an integrated healthcare intervention to decrease mortality from breast and gynecological cancers is proposed for implementation through a Well Woman Clinic. The operations and logistics of such a clinic are discussed in this chapter. The pros and cons of horizontal and vertical delivery of healthcare services and the benefits of an integrated approach to screen for cancers in women are outlined. The methodology proposed is to screen for breast and cervical cancer and to diagnostically test symptomatic postmenopausal woman so as to detect endometrial and ovarian cancers at an early stage. The healthcare personnel required to carry out these tasks and the training and telemedicine support to ensure quality and consistency of services provided also are discussed. The need to have a robust and enforced referral system in place to provide a continuum of care for those women who are tested positive for malignancy and need definitive treatment and or surgery is emphasized. The methodology may need modifications for adaptation to individual countries and resources available; the core principle, however, of this proposal is integration of a well woman exam with screening and early diagnosis of multiple commonly occurring cancers affecting women. Some variation in the screening methodology, particularly for cervical cancer, is expected from one country to another and will be influenced by factors such as existing national or professional body guidelines or resource limitations.

Appendix: Design, Layout, and Construction of a Well Woman Clinic in a Developed Country

Jennifer C. Garza

Introduction

The well woman clinic concept described previously may also be useful to help the underserved and/or indigent population in large cities of developing countries. The logistics of constructing a clinic in such a setting is described in this appendix. This description is in contrast to the bare bones approach outlined previously, keeping in mind that a clinic in a developed nation utilizing the same project design will have to meet certain minimum standards, and the funding available is significantly higher than in resource-poor settings (Fig. 17.6).

Fig. 17.6

Floor plan of a typical well woman clinic (Design by Robert Mason, Director, Architect, HCA/Gulf Coast Division, Houston, TX. Used with permission.)

Constructing a Well Woman Clinic

There are various factors to take into account when designing and building such a project. Building one from scratch, often called a “Greenfield” project, involves many steps. This appendix is designed to familiarize the reader with the various steps in the process. The process will vary depending on resources available at each specific clinic location.

Choosing a Location

It would be preferable to find a shelled out space in an existing building if one does exist. Also, an easily identifiable location will ensure the patient’s ability to find the clinic and will ensure success. It is recommended to establish contact and work with local authorities to determine if land could be donated, if the determination is to build a free-standing clinic.

Cost to Build the Clinic

The cost for construction varies greatly and depends on the location, labor availability, and material availability. In US dollars, constructing medical office building space can range anywhere from $160 to $220/square feet in metropolitan areas. It will be important to determine what types of constraints will be present at the location, but it will also be important to speak with local architects and contractors to show you examples of completed work done along with cost to determine an average cost for the well woman clinic.

Budget for the Clinic Space

The budge for a well woman clinic space would include:

• Architect and Engineering Fees

• Land

• Contractor Fees for Construction and Build-out

• A 20 % contingency budget

• Furniture, Fixtures, and Equipment

Selecting an Architect

If possible, it is important to select an architect who is familiar with the location where the clinic will be built. Knowing the local building requirements will speed up the permit process. The architect familiar with the local area will also be aware of any constraints present in the market. For example, if certain materials are not permitted as part of the construction, the architect can make changes to the design specifications to allow for that. If certain utilities are not readily available, the architect can redesign the space to take into account these constraints. Architects also usually can recommend engineers for the project if necessary.

Architectural Design Process

There are several phases in the architectural design process. To cut down on costs, researching medical office floor plans and selecting one to base the clinic space upon will be beneficial. Many floor plans can be found on the Internet, and several should be provided to illustrate the medical office layout that should suffice for the well woman clinic. For purposes of the well woman clinic, most of the programming and schematic phases have been completed.

Programming

Programming is the activity of determining the set of needs the building or space needs to fulfill. In this part of the process, you define what exactly is needed; for example, the number of exam rooms, the lobby, the physician’s office, etc.

Schematic Phase

Schematic phase is the first step in the design process for planning the clinic space. The architect will typically sketch out the space in this phase. This is a high-level design for the space and will generally specify the dimensions of the different components in the space. It will also show doorways and egress, and will allow you to look at the “flow” of the space.

Design and Development

During design and development, the scheme is refined into the final design. During this portion of the process, different sets of drawings for mechanical, electrical, and communication are designed and specified. For example, an issue that will be addressed will be the number of electrical outlets needed. Communication drawings show where data lines will be located or “dropped” in the various work spaces. Also, keep in mind the logistics of patients, family members, equipment, and personnel in the space when designing the different areas.

Construction Documents

The purpose of the various sets of drawings is to specifically spell out everything that is needed in order to construct the space. Construction documents typically are submitted to permit authorities. These authorities typically review the documents, and, in most cases, they will add comments and will prescribe required revisions to the design before the permit is granted. If the architect is familiar with the location, there will more than likely be a faster turnaround time to securing the permit.

Selecting a Contractor to Build the Well Woman Clinic

Before final construction documents are created, it is important to begin to identify a construction company or a contractor that will build-out the clinic. The contractor is in charge of procuring all the different trades needed for the project. For example, trades needed typically include flooring work, masonry, plumbing, electrical work, painting, cabinetry, etc. It is very important that a good working relationship exist with the contractor. It is suggested that one interviews several contractors. It is also important for them to demonstrate various completed projects. If possible, physically travel to locations where work was completed by these contractor candidates to determine the quality of their work.

Bidding Out the Project

If possible, the project should be bid out to at least three reputable contractors. The architect firm should be responsible for setting the “rules” for the bid. They should specify when the bid is due and the specific items that need to be addressed on the bid. For this part of the process, make sure contractors are as detailed as possible in the bid. Make sure all items have been addressed. If one contractor’s price is significantly different from the others, it is more than likely that a component of the project was missed in the proposal. Other topics to take into consideration are the time it takes to order and receive supplies. It also is important to ask for an estimated time frame or schedule for construction completion. It is common to request a project timeline with key milestones identified. After questioning contractors and deciding on the price, it is customary to formally award the project to the contractor selected for the project in the form of written communication. In this communication, it is important to reference the project number if one was assigned and the total dollar amount that was agreed to. It is also customary to let the other contractors know by written communication that they were not selected for the project.

Change Orders

Change orders are changes requested after the original scope of the project has been agreed to. An example of a change order would be if it was decided to go with finished concrete for the flooring vs. ceramic tile flooring as bid originally. In this case, there very well may be a savings to the project because of the change in materials. If there is a savings, then a credit for the price specified in the original bid is due. Most projects have several change orders. Make sure both parties agree to a change order and sign off as well as date the change order. Adherence to this process will prevent any misunderstandings and arguments later. It is also important to decide how change orders will be paid and credited as the project progresses. This should be negotiated before the project commences.

Payment to Contractors

Usually, there is a payment at the beginning of the project in order for the contractor to procure supplies and labor. Generally, as the project goes through completion, there are different payment stages. It is important to negotiate the payment terms and schedule before the project is started. Again, proper documentation of these terms should be completed prior to the project commencing.

Contingency Budget

It is typical in a construction project that unanticipated issues previously not identified in the design process arise. For example, in an existing building, a wall may be demolished and then it is discovered that the plumbing will have to be rerouted or replaced due to its age. For this purpose, it is important to determine a contingency budget. It should be based on the overall project cost and can range from 10 to 20 % depending on the unknown conditions.

Well Woman Clinic General Layout

We provide schematics for typical clinic space with dimensions in the sections that follow. Sometimes, contractors can work with as little as this information to begin renovations or work. Again, it is important to know building code requirements in the local area. Generally speaking, the clinic should range from 1,000 to 2,200 square feet (Fig. 17.6).

Waiting Room Space

The waiting room space should be the first space that you walk into in the clinic. The size of the waiting room will be determined by the anticipated needs of the patients. If a large amount of family will accompany the patient, then it may be wise to develop a waiting porch area outside the clinic. “Gang” seating is also preferable. These types of chairs are connected to each other and make it difficult for visitors to rearrange the layout. A waiting room can be efficiently used and can be relatively small at 200 square feet. At 200 square feet, it could hold ten patients waiting at one time. At 400–500 square feet, the waiting room could hold well over 20 people at one time.

The patient would walk up to the check-in counter. The reception desk should consist of a walk-up counter. It could be enclosed or partitioned off with a transparent type of window, or it could be open to the public but partitioned off from the waiting room by the counter itself.

Exam Room [2]

Exam rooms should measure from 100 to 150 square feet. Exam rooms of this size should be large enough to fit a basic obstetrics exam table, an ultrasound machine, one or two seats, a counter with sink, and cabinets above the sink.

The clinic should have two exam rooms. One will be used for well woman examinations and various testing. The second exam room will be used for sonography and procedures.

Procedure Room [1]

The procedure room could be built larger than the exam rooms if necessary. For example, the waiting room could me made smaller so that one of the exam rooms could be made larger for use as a procedure room. This room would be used for cryotherapy and other clinical procedures.

Other Spaces

Other spaces to be included and planned are Office for Physician/Practitioner, Small Break Room/Lounge, and Closets.

Materials to Consider When Building the Clinic

Using durable materials is important for ensuring that the clinic hold up to patient use and possible harsh environmental factors. For the flooring, the sealed concrete floor should be sufficient. Ceramic tile throughout would also be a good choice. Walls should be built to local standards. Epoxy paint on cinder block will suffice for all areas. For a more decorative, yet cost-effective approach, ceramic tile could also be installed along the perimeter of the wall. This could serve as wall protection. For counters with sinks, it is highly recommended that a solid surface countertop be installed. Corian is a type of solid surface material that can be made for counters that will withstand water and is durable. Sometimes you will find laminate used in clinics, but laminate has a tendency to chip or warp with age. Another consideration is to pour out concrete countertops and seal them. This will be very durable and will be easy to clean in the long term.

Bibliography

1.Robert Mason, B.S. (Building Sciences), B.A., Architecture, Director, Facilities Services Group, HCA/Gulf Coast Division.

2.Ginger Baecker, Director of Satellite Clinics, Woman’s Hospital Texas.