关键词: 家庭医生签约服务, 健康管理, 临床工作能力, 评价, 指标体系

Abstract: Background  The capability of family doctor teams is a key factor involved in effective delivery of the contracted services，so corresponding capability building is very important.But there is still lack of a system that can objectively evaluate the building.Objective  To construct a scientific and practical service capability building evaluation system to assess the advantages and disadvantages of service capability building in family doctor teams，improving the orientation and accuracy of the building.Methods  We drew up the initial version of the family doctor service capability building evaluation system based on literature review and results of expert consultation.Then，the contents of the system were revised after being discussed in another two rounds of consultation（one was conducted on December 14，2017，and the other was on January 14，2018） with 13 experts who had a good grasp of general practice theories，and three models of care〔patient-centered medical home（PCMH），person-centered integrated care（PCIC） and people-centered active care（PCAC）〕.Results  The attending rates for the later first and second round of consultation were 100.0%（13/13），92.3%（12/13），respectively.The final system covers 8 first-level indicators：training of skills used for delivering contracted services，person-centered care and communication，accessible and continuous services，team-based planning services，collaborative services and management，specific group identification and management，application of information systems and tools，and quality testing and improvement.In addition，35 second-level indicators and 113 third-level indicators are also included.Conclusion   Our family doctor team service capability building evaluation system fully demonstrates that the contracted services delivered by the team are person-centered，accessible and continuous services in essence，which can be easily conducted to promote people's health with targeted interventions，and can be referred for family doctor team service capability building.

Key words: Contracted family doctor services, Health maganment, Clinical competence, Assessment, Index system