Construction of an index system for workplace services by family doctors in China: a two-round Delphi study

Abstract

Background

Primary health care for young and middle-aged individuals is often overlooked, with insufficient placed on workplace services provided by family doctors. This study aims to establish expert consensus on a comprehensive set of scientific and systematic indicators for workplace services provided by family doctors.

Methods

Based on prior literature and the established Structure-Process-Outcome (SPO) model, we designed two rounds of expert consultation using the Delphi method. A panel of 35 experts from diverse fields—including academia, medical institutions, and relevant health authorities—was composed, collectively possessing substantial expertise in healthcare delivery. The experts indicated their levels of agreement regarding the importance of different indicators for assessing workplace services provided by family doctors. Consensus was defined as achieving a threshold of 70% agreement.

Results

After two Delphi rounds, 42 out of 46 indicators reached high consensus, with authority coefficients > 0.7 and coefficients of variation < 0.25. Consensus on high importance (scores 7–9) ranged between 71.43% and 97.14% across four dimensions: organizational structure and management (5 indicators, 88.57%–94.29% consensus); content and form of services (17 indicators, 77.14%–94.29% consensus); synergy, incentive, and feedback mechanisms (10 indicators, 85.71%–97.14% consensus); and effectiveness of services (10 indicators, 71.43%–85.71% consensus).

Conclusions

This study establishes four dimensions and 42 potential indicators that serve as a foundational framework for assessing and improving workplace services offered by family doctors, and provide essential guidance for health management among individuals in the workplace. The high consensus achieved among experts concerning specific indicators associated with such workplace services prompts their practical implementation to provide an objective basis for evidence-based health management within workplace populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-026-03192-x.

Background

According to the International Labor Organization (ILO), 2.34 million people die each year from work-related accidents and diseases, with diseases accounting for the majority (an estimated 2.02 million) of these deaths [1]. These issues can result in direct or indirect health-related costs, thereby imposing enormous burdens on individual employees and their families, businesses, and societal welfare [2–4]. China boasts the world’s largest labor market with a total number of laborers that has grown to 402 million people by the beginning of 2022 [5]. Moreover, because of the blurred boundaries between work and personal life, China’s occupational populations may be exposed to elevated stress and experience more pronounced physical and mental health issues compared with similar populations in most other countries [6]. Starting with the Alma-Ata Declaration of the World Health Organization (WHO) in 1978, primary health care has been identified as a priority for developmental strategies spanning all stages of life. Notwithstanding this consensus on the importance of health services, access to such services for workers in workplaces has not correspondingly expanded [7].

The WHO and ILO introduced a series of policies that call for and support the integration of work-related health problems into the management and treatment of primary health care, such as the basic occupational health service (BOHS) [8]. Some countries have taken measures to promote the integration of primary health care into occupational health services, thus enabling primary health care services to detect and intervene early in work-related health problems. For example, family doctors in the UK have access to evidence-based educational resources and web-based information on the links between work and health. In the Netherlands, family doctors view working conditions as part of the patient’s social context, and actively collaborate with occupational therapists [9]. Similar initiatives have been undertaken in Iran [10], India [11], China, and other Asian countries to improve health management of the occupational population through primary health care interventions. In China, Shanghai took the lead in exploring workplace services provided by family doctors by introducting the “1 (family doctor) + 1 (district hospital) + 1 (municipal hospital)” model in 2013 [12], and issued guidelines in 2021 to promote contracting with occupational groups [13].

Despite a large body of literature highlighting the importance of primary health care for occupational populations, there is no established general framework for assessing workplace services provided by family doctors, possibly as a consequence of substantial differences across primary health care systems. Existing evaluation methods for family doctor services rely on a wide range of aspects. For instance, the UK introduced the Quality and Outcomes Framework (QOF) to reward high-quality care on the basis of various clinical, organizational, and patient experience indicators [14]. In the United States, assessment tools include the Primary Care Assessment Tool (PCAT) [15], and the Vision and principles of a quality measurement strategy for primary care [16]. Kringos et al. followed the Structure-Process-Outcome (SPO) model to construct an indicator system for monitoring primary health care activity in Europe [17].

A general framework for assessing workplace services provided by family doctors is critically needed for several interconnected reasons. First, the lack of standardized evaluation criteria makes it difficult to compare service quality across different regions and institutions, hindering the identification and dissemination of best practices [18]. Second, without a comprehensive assessment framework, policymakers lack evidence-based tools to guide resource allocation and prioritize interventions for workplace health services [19]. Third, given China’s unique occupational health landscape—characterized by rapid industrialization, diverse workplace environments, and specific health challenges such as work-related injuries and lifestyle-related diseases [20]—a context-specific yet generalizable framework is essential to effectively address the distinct needs of the Chinese working population.

In China, most studies have focused on the assessment of family doctor services directed at key populations and older adults in the community [21, 22], potentially influenced by the fact that young and middle-aged individuals may not constitute the primary contacted population [23]. A few scholars have researched and constructed a competency model for GPs and indicators for the evaluation of family doctor services [24, 25]. Several studies have focused on migrant workers in China, examining aspects such as health-related quality of life and work-related stress among white-collar workers and management staff [26], as well as the utilization of traditional Chinese medicine [27]. Additionally, extensive research has focused on the health status of white-collar employees in China, including investigations into the validity of assessment instruments for sub-health status in urban Chinese populations [28], explorations of topics such as a healthy work environment [29], occupational stressors and well-being [30], the threat of work addiction anxiety on occupational health, and the identification and comparison of health risk indicators for common chronic diseases among different occupational groups [31–33].

Existing research on workplace health interventions for family doctors lacks a comprehensive indicator system for guidance. To fill an important gap in current health management practices that primarily target the elderly and children, we address the specific health needs of workplace populations. The purpose of this study was two-fold: (1) to identify important dimensions for assessing family doctor services directed to the workplace population, and (2) to develop a Delphi-based index system for evaluating and improving workplace services provided by family doctors to workplace populations in China. The resulting index system provides theoretical and practical guidance for the intervention strategies of family doctors, improving the health management of workplace populations. In summary, this study aims to construct and validate a comprehensive set of indicators for evaluating workplace services provided by family doctors using the Delphi method.

Methods

Study design

This research used the Delphi technique to develop and validate an indicator system for workplace services provided by family doctors in Shanghai, China. We adopted the Delphi method because it was designed as a systematic, interactive forecasting and consultation method to collect and summarize the opinions of experts on a given issue [34]. Our study group conducted two rounds of anonymous consultation with 35 experts. The decision to conduct two rounds was based on established Delphi methodology principles and predetermined consensus criteria. Delphi studies typically achieve consensus within two to three rounds, as continuing beyond this point often yields diminishing returns and increases expert fatigue without substantial improvement in consensus quality [35, 36]. The consensus threshold was set at ≥ 70% agreement combined with a coefficient of variation ≤ 0.25, establishing dual criteria to ensure both high agreement and low variability among expert responses. These predetermined stopping rules provided objective measures for determining when adequate consensus had been reached. Qualitative comments on questionnaires were collected and translated into quantitative data in the first round, and the results of the first round were returned to the experts along with corresponding questionnaires in the second round. Specifically, we followed a three-phase process involving dimension and indicator preparation, panel selection, and the Delphi scoring process (Fig. 1).

Fig. 1.

The three-phase process adopted in this study

Phase 1: dimension and selection of relevant indicators

To identify indicators for assessing workplace services offered by family doctors, group members initially proposed and ranked evaluation indicators based on relevant literature and the classic SPO model [37], which aims to comprehensively evaluate the quality of health care services for organization and management purposes [38]. Indicator selection focused on four dimensions: (a) organizational structure and management (6 indicators); (b) content and form of services (15 indicators); (c) synergy, incentive, and feedback mechanism (8 indicators); and (d) effectiveness of services (10 indicators). Individual indicators and the questionnaire used in this study are detailed in the Supplementary.

Phase 2: expert selection

Panel members in the Delphi process are expected to bring in-depth knowledge and diverse perspectives on the research topic under scrutiny, combined with reputable credentials in the relevant field [39]. Experts were recruited from Shanghai, China, between November 2022 and December 2022. Shanghai was selected as the recruitment location since it pioneered workplace-based family doctor services in China, with implementation beginning in Pudong in 2010 and expanding citywide by 2012 [40]. This concentration of implementation experience ensured that all participants possessed direct operational knowledge necessary for developing contextually grounded assessment indicators [35]. We employed purposive sampling to recruit a multidisciplinary expert panel through professional networks and relevant organizations in Shanghai [41].

A panel of 35 experts was recruited for this study. This sample size was determined based on practical feasibility considerations, including the availability of qualified experts with relevant implementation experience in Shanghai, resource constraints for conducting multi-round consultations, and the need to balance diverse professional expertise with panel manageability. The panel composition prioritized ensuring adequate representation across key professional domains while maintaining the depth of expertise necessary for developing contextually grounded assessment indicators. The inclusion criteria were: (a) education at undergraduate level or above; (b) holding a junior professional title or above in the field; (c) a minimum of 5 years of professional experience in at least one of the following fields: primary health care delivery, occupational health services, family medicine practice, public health administration, or workplace health policy research; (d) familiarity with family physician-related work and research advances; and (e) willingness and availability to participate through all survey rounds. Expert credentials were verified by research team members through review of professional certifications, employment records, and publication histories, following established guidelines for Delphi studies [42–44]. We retained 35 experts who met al.l criteria and volunteered to participate. Despite single-city recruitment, we actively sought diversity in institutional backgrounds, with representation from research institutions, health administrative departments, and medical institutions, as shown in Table 1.

Table 1.

Basic expert information

Basic information	Frequency	Percentage
Gender
Male	9	25.71%
Female	26	74.29%
Education level
Doctor	10	28.57%
Master	13	37.14%
Undergraduate	12	34.29%
Years of work
≤ 10 years	11	31.43%
11 ~ 20 years	10	28.57%
21 ~ 30 years	12	34.29%
>30 years	2	5.71%
Title
Full Senior	11	31.43%
Associate Senior	11	31.43%
Intermediate	11	31.43%
Junior	2	5.71%
Institutions
Research institutions (e.g. universities)	10	28.57%
Relevant Health Authorities	3	8.57%
Medical institutions (Hospital administrators)	9	25.71%
Medical institutions (Medical staff)	13	37.14%

All experts were recruited from Shanghai, China

Phase 3: the Delphi scoring process

Following extensive consultation, we carried out the Delphi scoring procedure over two rounds spanning the period between November 2022 and December 2022.

Round 1

Our first round of questionnaires initially incorporated a system comprising four dimensions and 39 evaluation indicators. These questionnaires were electronically distributed to invited experts who were asked to estimate their level of understanding for the various dimensions and indicators included in this initial assessment. Subsequently, experts were asked to rate the importance of each dimension on a nine-point scale, ranging from 1 to 9. Specifically, scores of 1–3 were categorized as low importance, 4–6 as moderate importance, and 7–9 as high importance, with higher scores indicating greater importance. Additionally, experts could propose the deletion of any indicators deemed unnecessary. Each dimension in the questionnaire allowed experts to provide suggestions based on their practical experience and theoretical insights, and to propose changes to the way in which indicator descriptions were worded. In this round, each expert was also required to provide basic information about their familiarity with the evaluation system and the basis for their assessment. Familiarity was scored using a 0.2–1.0 rating scale where 0.2 corresponded to very unfamiliar, 0.4 to less familiar, 0.6 to generally familiar, 0.8 to quite familiar, and 1.0 to very familiar. The assessment basis was scored using at three levels—large, medium, and small—corresponding to decreasing value. For example, “practical experience” was scored using 0.5/0.4/0.3 for large/medium/small, “theoretical basis” using 0.3/0.2/0.1.

Round 2

During the second round of the online questionnaires, seven new indicators proposed by the experts in the first round were included after discussion with the research team. The sections relating to basic information about experts and open-ended entries were removed. Results from the first round of expert assessments were included to facilitate further evaluation by the experts. The scoring principles remained consistent with those adopted for the first round, with scores ranging between 1 and 9. To ensure timely progression of the study, experts were given one week to complete the second round of questionnaires.

Reaching consensus

Diverse perspectives exist on appropriate standards for determining consensus in Delphi analysis. Some studies define consensus as achieving over 95% agreement in the first Delphi round, while others define consensus as involving at least 51% agreement among respondents [45]. We considered a 50% consensus threshold as lenient, and a 95% threshold as excessively stringent. Following relevant research guidelines, we selected a threshold value of 70% [46, 47]: consensus is achieved when at least 70% of the experts concomitantly judge a given indicator to be of either low importance (scoring 1–3), moderate importance (scoring 4–6), or high importance (scoring 7–9). Consensus for indicators was achieved after two rounds of expert scoring, provided that at least one round met the 70% agreement threshold. For newly added indicators, consensus was achieved if they reached the 70% agreement level in the second round. The degree of variation in expert scoring was evaluated using the coefficient of variation, with a value below 0.25 indicating a high level of agreement among experts. If the coefficient of variation exceeded 0.25, the indicator was considered as an outlier and was therefore removed [48]. After the two rounds of Delphi consultation, the research team incorporated indicators with consensus scores falling between 7 and 9 and a coefficient of variation less than 0.25 into the final evaluation system.

Data analysis

We compiled descriptive statistics to capture expert characteristics and responses to each proposition for both Delphi rounds. Themes were synthesized through discussion and summaried in tables. Statistical information was analyzed using Excel 2010 and STATA SE 17.

Quality control

To enhance the scientific accuracy of the results, experts from diverse backgrounds were engaged to mitigate potential bias associated with our findings. Furthermore, to ensure precision and completeness of the collected questionnaires, any questionnaires containing ambiguous statements were further scrutinized in collaboration with the expert for clarification and validation. If more than 20% of a questionnaire was incomplete, it was deemed invalid and excluded from further analysis.

Results

Profile of participants

We enrolled a panel of 35 experts from the fields of health care (management), community health, general medicine, and education. The expert panel had an average of 17.29 (± 9.43) years of working experience, and included medical staff (13, 37.41%), hospital administrators (9, 25.71%), university researchers (10, 28.57%), and relevant health authorities (3, 8.57%).

The present study involved two rounds of questionnaires. All 35 experts gave feedback in both rounds with a 100% positive response rate, indicating that the experts were highly engaged in both rounds. The authority coefficient exceeded 0.7, thus confirming the suitable level of authority provided by the experts and the reliability of the Delphi results. Table 1 presents detailed demographic characteristics of the experts involved in both rounds.

Main findings from the Delphi process

Round 1

In the first round of consultation, the consensus of “high importance” was achieved for 21 of the 39 indicators spanning four dimensions. Specifically, for the organizational structure and management dimension the following indicators reached consensus: “Designation of a director heading the management center associated with workplace services offered by family doctors” (77.14%), “Subdividing workplace areas and assigning medical and nursing staff accordingly” (94.29%), “Clear delineation of roles among workplace personnel, forming a cohesive team for workplace services” (88.57%), “Establishment of a clear workflow” (80%), “Clearly identifiable targets for young and middle-aged individuals” (71.42%).

From the dimension of content and form of services, a consensus of “high importance” was achieved for 8 of 15 indicators, including “Regular implementation of workplace services” (71.43%), “Delivering health assessment services tailored to white-collar workers in the workplace” (77.15%), “Management of online platforms (such as public accounts/WeChat groups) for young and middle-aged individuals” (85.72%), “Implementation of services tailored to the needs of white-collar workers” (82.86%), “Development of clear codes and standards for workplace services” (80.01%), “Active enrollment of family doctors with white-collar individuals in the workplace” (71.14%), “Establishment of comprehensive health records for contracted young and middle-aged individuals” (85.71%), “Deployment of online consultation services for contracted young and middle-aged individuals” (80%).

For the synergy, incentive, and feedback mechanisms dimension, the following indicators achieved “high importance” consensus: “Participation of a team of family doctors in workplace services” (79.99%), “Support from workplace entities such as businesses, unions, branches, and other similar entities” (80%), “Collaboration agreements with workplace entities, such as businesses and unions” (74.28%), “Endorsement by local government policies” (80%), “Financial incentives for primary care staff engaging in workplace services” (91.43%), “Preferential treatment for medical and nursing staff involved in the workplace services in merit evaluations, awards, and title promotions” (80%), “Positive motivational impact on involved individuals” (82.85%), “Establishment of feedback channels for young and middle-aged individuals, regarding service needs or satisfaction” (88.56%).

The indicators associated with the effectiveness of services dimension did not achieve a “high importance” consensus (< 70%). Some of these indicators showed relatively high levels of agreement, such as “Achieve a 30% sign-up rate for young and middle-aged population,” “Reach a 50% contracted community access rate for young and middle-aged population,” “Maintain an 80% normative management rate of diabetes among young and middle-aged populations,” and “Sustain an 80% normative management rate of hypertension among young and middle-aged populations.” Table 3 lists the scores for each indicator during the first round. Within the dimensions of synergy, incentive, and feedback mechanisms, consensus was unequivocally reached while designating all indicators as of “high importance.” At the same time, none of the indicators within the dimension of basic effectiveness reached unanimous agreement. In addition to the initial 39 indicators, seven experts suggested 7 new indicators, which we discussed and subsequently adopted (Table 2)

Table 3.

Results for the two rounds of expert scoring

	Round one				Round two
	Suggested deletion	Rank1-3	Rank4-6	Rank7-9	Suggested deletion	Rank1-3	Rank4-6	Rank7-9
Organizational structure and management
Designation of a director heading the management center associated with workplace services	2.86%	5.71%	14.29%	77.14%*	0.00%	0.00%	5.71%	94.29%*
Subdividing workplace areas and assigning medical and nursing staff accordingly	2.86%	0%	2.86%	94.29%*	0.00%	0.00%	5.71%	94.29%*
Clear delineation of roles among workplace personnel, forming a cohesive team for workplace services	2.86%	0%	8.57%	88.57%*	0.00%	0.00%	5.71%	94.29%*
Regular meetings to promote workplace services	5.71%	0%	37.41%	57.14%	0.00%	0.00%	31.43%	68.57%
Establishment of a clear workflow	2.86%	0%	17.14%	80%*	5.71%	0.00%	5.71%	88.57%*
Clearly identifiable targets for young and middle-aged individuals	2.86%	0%	25.71%	71.42%*	2.86%	0.00%	5.71%	91.43%*
Added: Establishment of dedicated on-site management units within community health centers	-	-	-	-	5.71%	2.86%	25.71%	65.71%
Content and form of services
Establishment of a workplace center for family doctor services	5.71%	2.86%	22.86%	68.57%	0.00%	2.86%	11.43%	85.71%*
Regular implementation of workplace services	2.86%	0%	25.72%	71.43%*	0.00%	0.00%	5.71%	94.29%*
Minimum monthly frequency of workplace services	2.86%	5.71%	22.85%	68.57%	0.00%	2.86%	17.14%	80.00%*
Provision of workplace rehabilitation physiotherapy services	5.71%	5.71%	25.71%	62.86%	0.00%	0.00%	22.86%	77.14%*
Delivery of personalized one-to-one health consultation services	2.86%	2.86%	25.71%	68.57%	0.00%	0.00%	14.29%	85.71%*
Delivery of health assessment services tailored to white-collar workers in the workplace	5.71%	0%	17.14%	77.15%*	0.00%	0.00%	8.57%	91.43%*
Delivery of maternity-related health services	5.71%	0%	31.43%	62.86%	0.00%	2.86%	25.71%	71.43%*
Delivery of stress relief and burnout-related health services	5.71%	2.86%	22.86%	68.56%	0.00%	0.00%	20.00%	80.00%*
Management of online platforms (such as public accounts/WeChat groups) for young and middle-aged individuals	0%	0%	14.29%	85.72%*	0.00%	0.00%	14.29%	85.71%*
Implementation of services tailored to the needs of white-collar workers	5.71%	0%	11.43%	82.86%*	0.00%	0.00%	5.71%	94.29%*
Development of clear codes and standards for workplace services	5.71%	0%	14.29%	80.01%*	0.00%	0.00%	8.57%	91.43%*
Active enrollment of family doctors with white-collar individuals in the workplace	0%	0%	22.86%	77.14%*	0.00%	0.00%	8.57%	91.43%*
Establishment of comprehensive health records for contracted young and middle-aged individuals	2.86%	0%	11.43%	85.71%*	0.00%	0.00%	11.43%	88.57%*
Deployment of online consultation services for contracted young and middle-aged individuals	5.71%	2.86%	11.43%	80%*	0.00%	0.00%	8.57%	91.43%*
Facilitation of referral services for contracted young and middle-aged individuals	8.57%	2.86%	25.71%	62.86%	0.00%	0.00%	5.71%	94.29%*
Added: Implementation of on-site health promotion services targeting white-collar workers	-	-	-	-	0.00%	5.71%	5.71%	88.57%*
Added: Delivery of personalized health education sessions based on individual health assessments	-	-	-	-	0.00%	0.00%	17.14%	82.86%*
Added: Delivery of health-related consultation services for children and elderly relatives of occupational groups	-	-	-	-	0.00%	0.00%	11.43%	88.57%*
Synergy, Incentive and Feedback Mechanism
Participation of a team of family doctors in workplace services	2.86%	0%	17.15%	79.99%*	0.00%	0.00%	2.86%	97.14%*
Support from workplace entities such as businesses, unions, branches, and other relevant entities	2.86%	0%	17.15%	80%*	2.86%	0.00%	5.71%	91.43%*
Collaboration agreements with workplace entities such as businesses and unions	2.86%	0%	22.85%	74.28%*	0.00%	0.00%	11.43%	88.57%*
Endorsement by local government policies	5.71%	0%	14.29%	80%*	0.00%	0.00%	11.43%	88.57%*
Financial incentives for primary care staff engaging in workplace services	2.86%	0%	5.71%	91.43%*	0.00%	0.00%	5.71%	94.29%*
Preferential treatment of medical and nursing staff involved in workplace services via merit evaluations, awards, and title promotions	8.57%	0%	11.43%	80%*	0.00%	0.00%	14.29%	85.71%*
Positive motivational impact on involved individuals	2.86%	0%	14.29%	82.85%*	0.00%	0.00%	11.43%	88.57%*
Establishment of feedback channels for young and middle-aged individuals regarding service needs or satisfaction	2.86%	0%	8.57%	88.56%*	0.00%	0.00%	2.86%	97.14%*
Added: ·Introduction of market mechanisms to enhance compensation for contracting family doctors	-	-	-	-	5.71%	0.00%	8.57%	85.71%*
Added: Delivery of medical and health services through the integration of external resources or within medical facilities	-	-	-	-	2.86%	0.00%	2.86%	94.29%*
Effectiveness of services
Achieve a 30% sign-up rate for young and middle-aged populations	2.86%	5.71%	31.43%	69.99%	2.86%	5.71%	11.43%	80.00%*
Attain an 80% accuracy rate in contracting with young and middle-aged individuals	2.86%	11.43%	28.57%	57.14%	0.00%	2.86%	17.14%	80.00%*
Reach a 50% contracted community access rate for young and middle-aged populations	0%	11.43%	22.85%	65.71%	2.86%	5.71%	14.29%	77.14%*
Maintain an 80% adherence to contracted communities for young and middle-aged populations	0%	11.43%	31.43%	57.15%	0.00%	5.71%	22.86%	71.43%*
Achieve a 40% utilization rate of family doctor visits by the young and middle-aged populations	0%	8.57%	37.14%	54.29%	0.00%	0.00%	25.71%	74.29%*
Maintain an 80% normative management rate of diabetes among young and middle-aged populations	0%	8.57%	25.71%	65.71%	0.00%	2.86%	22.86%	74.29%*
Sustain an 80% normative management rate of hypertension among the young and middle-aged populations	0%	5.71%	25.71%	68.03%	0.00%	2.86%	20.00%	77.14%*
Gather essential data on pregnant women within the workplace area	0%	8.57%	31.43%	60%	2.86%	2.86%	11.43%	82.86%*
Ensure uninterrupted workplace service operations during emergencies (such as epidemics)	5.71%	8.57%	31.43%	54.29%	2.86%	2.86%	28.57%	65.71%
Attain a 60% satisfaction rate with workplace services among young and middle-aged populations	0%	8.57%	34.29%	57.14%	2.86%	2.86%	8.57%	85.71%*
Added: Improvement in health assessment results for the white-collar population (three-point approach)	-	-	-	-	2.86%	2.86%	8.57%	85.71%*

“-”: no participation in scoring, “Added”: indicators added by experts in the first round, “*”: consensus on indicators (> 70%)

Table 2.

Newly added indicators following advice from experts

Organizational structure and management
·Establishment of dedicated on-site units for managing services within community health centers.
Content and form of services
·Implementation of on-site health promotion services targeting white-collar workers. ·Delivery of personalized health education sessions based on individual health assessments. ·Delivery of health-related consultation services for children and elderly relatives of occupational groups.
Synergy, Incentive, and Feedback Mechanisms
·Introduce market mechanisms to enhance compensation for contracting family doctors. ·Provide medical and health services through the integration of external resources or within medical facilities.
Effectiveness of services
·Improvement in health assessment results for the white-collar population (three-point approach).

Round 2

Of the 18 indicators that failed to achieve “high importance” consensus during the first round, 16 reached consensus during the second round, including “establishment of a workplace center for family doctor services” (68.57% to 85.71%), “minimum monthly frequency of workplace services” (68.57% to 80.00%), “provision of workplace rehabilitation physiotherapy services” (62.86% to 77.14%), “conducting personalized one-to-one health consultation services” (68.57% to 85.71%), “delivery of maternity-related health services” (62.86% to 71.43%), “providing stress relief and burnout-related health services” (68.56% to 80%), and “facilitation of referral services for contracted young and middle-aged individuals” (62.86% to 94.29%). Additionally, within the dimension of service effectiveness, consensus regarding high importance was reached for all other basic effectiveness indicators during the second round, except for the indicator “ensure uninterrupted workplace service operations during emergencies (such as epidemics),” which showed an increase in consensus for “high importance” from 54.29% to 65.71%. Among the seven added indicators, consensus on the “high importance” of the indicator “establishment of dedicated on-site management units within community health centers” reached 65.71%. Within the organization structure and management dimension, the indicator “regular meetings to promote workplace services” did not reach consensus on high importance in either round, with rates increasing from 57.14% to 68.57%.

Following two rounds of expert scoring, strong consensus was achieved for 43 of the 46 indicators, which were rated as highly important. Specifically, within the organizational structure and management category, 5 out of 7 indicators (71.4%) achieved a consensus of “high importance.” In the content and form of services, all 18 indicators (100%) received a unanimous consensus of “high importance.” Similarly, within the synergy, incentive, and feedback mechanisms dimension, all 10 indicators (100%) achieved a consensus of “high importance.” In the effectiveness of services category, 10 out of 11 indicators (90.9%) reached a consensus of “high importance.” The coefficient of variation for the second round of scoring results indicated that, apart from one indicator (delivery of maternity-related health services), all others had coefficients below 0.25. Consequently, 42 indicators were proposed for inclusion in the final framework for evaluating workplace services provided by family doctors. Detailed results are presented in Table 3.

To illustrate the real-world implementation of our indicator system, we added examples of three representative effectiveness indicators that achieved high consensus.

First, the indicator “Maintain an 80% normative management rate of diabetes among young and middle-aged populations” required family doctors to establish systematic workplace diabetes care protocols. In practice, this involved: (1) conducting quarterly on-site HbA1c testing during work hours to minimize work disruption, (2) providing personalized medication adherence counseling in workplace health rooms, (3) collaborating with workplace cafeterias to offer diabetic-friendly meal options, and (4) maintaining integrated digital health records accessible to both employees and healthcare providers for continuous monitoring.

Second, the indicator “Reach a 50% contracted community access rate for young and middle-aged populations” measured the proportion of eligible workplace employees who actively engaged with family doctor services. Implementation strategies included: (1) establishing flexible on-site consultation schedules that accommodated different work shifts, (2) providing multiple service access channels such as face-to-face consultations, telemedicine platforms, and mobile health apps, (3) offering convenient appointment booking systems integrated with workplace management systems, and (4) tailoring services to workers’ occupational health risks and time constraints.

Third, the indicator “Improvement in health assessment results for the white-collar population (three-point approach)” evaluated measurable health improvements through a structured timeline. This involved: (1) a baseline comprehensive health assessment addressing occupational risk factors specific to office workers (e.g., sedentary lifestyle, computer vision syndrome, work-related stress), (2) a 6-month intermediate evaluation with targeted interventions such as ergonomic training and stress management workshops, and (3) a 12-month final assessment measuring outcomes such as blood pressure reduction, weight management, and stress level improvements, with family doctors providing individualized care plans throughout the process.

Discussion

In this two-round Delphi study, we developed a comprehensive index system of 42 indicators for assessing workplace services provided by family doctors. Some scholars have focused primarily on service content, service capabilities, and service methods when compiling process indicators, such as medical staff training, augmenting general practitioner capabilities [49, 50], diagnosing dizziness in elderly patients [51], assessing central sensitization in individuals with chronic pain and persistent physical symptoms [52], and integrating primary palliative care into general practitioner practice [53]. Several studies have emphasized outcome indicators, and adopted the Delphi method to assess chronic disease quality [54], identify crucial features for evaluating children suspected of appendicitis [55], and establish criteria for selecting health-related outcome measures within primary health care settings [56].

The development of indicators in this study is based on the Structure-Process-Outcome framework, which systematically covers the entire process of workplace services offered by family doctors. Notably, process indicators underscore the significance of the system feedback mechanism, while outcome indicators are more specific and operational. Furthermore, scholars have not extensively explored the establishment of a comprehensive indicator system for workplace contract services provided by Chinese family physicians [24, 50, 57]. The results of this study fill a current gap in the literature, and provide an initial outline for characterizing workplace services provided by family doctors. The indicator system introduced in this study will allow the development of a valid and reliable instrument for improving workplace services provided by family doctors. Experts from multiple professions reached robust consensus, providing a crucial foundation to support family doctors in delivering services to workplace populations.

Among structural indicators, “subdividing workplace areas and assigning medical and nursing staff accordingly” was identified as a top enabler and highly important for organization management. Studies have shown that the health of employees varies considerably depending on occupational status, and that lifestyle habits, social factors, and working conditions (including working overtime, rewards, and environmental and occupational hazards) can explain much of this health variation [58–60]. Therefore, individualized characterization of healthcare workers according to different workplace areas can facilitate the development of more targeted health services for working people. In addition, the team structure of family doctors represents an important part of primary health care services. Having common goals and mandates, clear processes and structures, well defined roles and responsibilities, and good team relationships (communication, trust, and respect) are regarded as teamwork facilitators [61–63].

In terms of process indicators, demand-oriented development of service plans for contracted clients is important in medical and health care [64, 65]. Currently, family doctor services in China are mainly provided by a team that usually consists of general practitioners, nurses, and public health physicians, providing health consultation, health assessment, health records, chronic disease follow-up, two-way referral, and other services [66]. Employees showed significantly poorer health and lower rates of health behavior maintenance compared with the general population [67], and are at high risk for musculoskeletal disorders (such as back, neck, and shoulder pain) [68], cerebrovascular and cardiovascular diseases [69, 70], dry eye complaints [71], and mental health problems [72]. Therefore, the content of workplace services should also include workplace rehabilitation physiotherapy services and health services related to stress relief to meet the needs of employees. Considering that work-life conflict is a significant risk factor for physical and mental health problems [73, 74], the inclusion of counseling on health issues related to the elderly and children as part of workplace services will help alleviate this source of stress for employees. Online consultation is a flexible, efficient, and cost-effective way for patients to consult their family doctors and relieves some of the pressure on primary care services [75]. Several studies have found that online counseling can save time and improve health problems such as diabetes and high blood pressure [76, 77]. Younger and employed adults are more likely to use online counseling, which improves self-care, communication, and engagement with clinicians [78].

Synergy, incentive, and feedback mechanisms are key components of health service management, involving cooperation and support from the family doctor team, government, enterprises, and health organizations. Teamwork and cooperation contribute to higher healthcare quality [79], and family doctors are encouraged to delegate certain tasks and patient follow-up activities to nurse assistants, which helps family doctors save time that can be used to examine and follow up additional patients, thus improving access to medical care [80]. Financial incentives enhance motivation among primary care staff and promote behavioral changes toward continuous quality improvement [81, 82]. Other incentives, such as rewards, benefits, and promotion of titles, also represent concrete suggestions to improve the attractiveness of contracted services, and to mobilize medical and nursing staff to provide services [83, 84]. Patient feedback is considered an integral part of quality improvement and professional development, facilitating reflection that leads to the translation of feedback into measurable behavioral change and quality improvement initiatives, making it easier to achieve performance improvement [85–87].

From the perspective of outcome indicators, workplace health service performance requires evaluation metrics that address the unique challenges of occupational health environments. Research on contracted family doctor services in China has demonstrated that successful implementation requires addressing population-specific access barriers and service delivery constraints [88]. Studies examining the elderly population’s utilization of primary care services highlight how contracted services must be tailored to overcome specific accessibility challenges [89], while evidence from southern China shows that service quality perceptions are significantly influenced by population-specific factors [90]. These findings emphasize that workplace populations similarly require specialized approaches to contracted service delivery. The occupational environment creates unique health challenges that traditional community-based indicators may not adequately capture. Office-based work environments contribute significantly to sedentary behavior patterns that increase health risks [91], while psychosocial work environments characterized by high job demands and effort-reward imbalances directly impact cardiovascular health outcomes . Furthermore, effective workplace health service delivery requires collaborative relationships between healthcare providers and occupational health service organizations to ensure comprehensive care coordination [92]. Key workplace-specific barriers include work schedule inflexibility that restricts healthcare access during traditional clinic hours, and the documented finding that workers without flexible leave policies are significantly less likely to seek timely medical care [93]. These employment-related constraints create distinct challenges for achieving healthcare utilization targets in occupational settings. The Chinese government’s Guiding Opinions on Promoting the High-quality Development of Contracted Family Doctor Services state that the coverage rate of contracted services for the whole population and key populations will be increased by 1–3% points annually, reaching 75% by 2035 . However, achieving these goals for working populations requires innovative service delivery models that address employment-related access barriers, integrate with existing occupational health frameworks, and accommodate workers’ unique scheduling and privacy requirements while maintaining service quality and effectiveness.

Limitations

This study has several limitations that should be acknowledged. First, recruiting all expert panel members from Shanghai, China may limit the generalizability of our findings to other Chinese regions with different development levels and to other countries with different healthcare systems. Future research should validate these indicators across diverse geographical regions within China and include international expert panels. Second, the criteria for different workplace services provided by family doctors have not yet been explored in detail, and family doctor services for the workplace population should be delivered in an easily accessible manner aligns with workplace characteristics. This aspect should be explored in greater detail by future studies.

Conclusions

This study developed an expert consensus framework for characterizing workplace services provided by family doctors. Our framework provides a basis for family doctors to initiate health management steps such as health counseling, health assessment, rehabilitation, and physical therapy services for young and middle-aged individuals. We identified four dimensions and 42 potential indicators that can be used to construct a system of service delivery by family doctors in the workplace. Our framework represents an important step toward facilitating the contracting of family doctors for workplace populations, and informs the development of operational tools to further optimize workplace health interventions.

Authors’ contributions

Study conception and design: Hong Liang, Jiaojiao Yu. Data collection: Jiewen Xiao, Xiangyang Yan. Data analysis: Junqiao Guo. Drafting of the article: Jing Guo. Critical revision of the article: Jiaoling Huang, Ying Qian. All author(s) read and approved the final manuscript.

Funding

This work was supported by the National Natural Science Foundation of China (Grant No. 72274122), Three-Year Action Plan of Shanghai Municipality Strengthens Public Health System Construction - Young Talent Program (No. GWVI-11.2-YQ54), and the think tank construction project of Shanghai Association for Science and Technology (No. AX-2223).

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted and approved by the Ethics Committee of Shanghai Tenth People’s Hospital (Ethics approval reference number: 2019-K173-02, approval date: August 14th, 2019). Experts could refuse to respond to the questionnaire surveys. Informed consent was taken from participants to participate in the study. The questionnaires were anonymous, and the data obtained were only used for research purposes. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.