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

摘要： 背景  家庭医生团队签约服务能力是有效开展签约服务的关键因素，因此相应的能力建设非常重要，但目前尚缺乏客观的服务能力建设评估指标体系。目的  构建一套科学、实用的用于评估家庭医生团队签约服务能力建设的指标体系，以有效监测和评估家庭医生团队签约服务能力建设的优势和不足，从而提升能力建设的方向性和内容精准性。方法  在查阅相关资料、咨询专家的基础上，初步拟定评价指标体系。遴选熟悉全科医学理论、以患者为中心的诊疗之家（PCMH）、以人为本的一体化服务（PCIC）模式、以人为中心的主动健康管理服务（PCAC）模式的专家13名，分别于2017-12-14、2018-01-14开展2轮专家会议，对评价指标体系进行讨论、修改。结果  2轮会议的专家参与率分别为100.0%（13/13）、92.3%（12/13）。建立的评估指标体系包括一级指标8个、二级指标35个、三级指标113个。一级指标分别为家庭医生团队签约服务技能培训、以人为中心的照护和沟通、提供可及性和连续性服务、以团队为基础提供计划性服务、提供协同服务与管理、人群识别与管理、信息系统和工具的应用、质量的监测与改进。结论  构建出的家庭医生团队签约服务能力建设评估指标体系，充分体现了家庭医生签约服务的以人为中心、健康促进及可及性、连续性服务内涵，具有很强的操行性和目标导向性，可以为家庭医生团队签约服务能力建设提供参考。

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