BEIs
The 20 BEIs generated 40 outcomes respectively: 20 positive results (successful events) and 20 negative results (failure events). The transcriptions in Chinese totalized 9,452 words. The data were coded through highlighting passages of text according to the research questions posed. There were 125 open codes that 71 codes were extracted from positive outcomes, and 54 codes from negative outcomes. The coding results suggested that most of the elements of competence mentioned in the coding data were consistent with the results of literature review. In addition, we found that the family physicians with outstanding performance were pronounced to mention some keywords about ‘online-healthcare service’. Therefore, we added 4 items: ‘Online health education’, ‘Online health promotion’, ‘Online health guide’, and ‘Online information exchange’.
Expert consultation
The experts mentioned that ‘Preventive medical service’ is a broad concept as a part of public health sciences including some items in the same dimension, such as ‘Health education’ and ‘Health management’. Therefore, experts suggested that the item ‘Preventive medical service’ should be modified to ‘Disease surveillance’.
In addition, the experts advised that item of ‘understanding and implementation of primary healthcare regulations’ and ‘frontier understanding of industry dynamic’ should be included in the dimension of “Service skills” and “Professionalism”, respectively.
Based on the experts’ comments, because the concept of the two items ‘Pursuit of progress’ and’ Learning and development’ in the dimension of “Professionalism” was relatively repetitive, these two items should be merged into one item as ‘Pursuit of progress and development’.
The experts suggested that the item ‘achievement oriented’ was not the necessary element of the competences for family physicians; furthermore, it was considered a difficult concept to evaluate. Therefore, it was excluded from the competency model. Table 1 shows the competency model, which contains a total of 35 competency elements and definitions from 4 dimensions for Chinese family physicians.
Table 1. Key elements for the evaluation of family physician service competence under the background of Internet Plus
Dimensions
|
Elements
|
Definition
|
|
1. Service skills
|
1a. General medical service
|
Basic general clinical medical expertise and skills in diagnosis and treatment
|
|
1b. Health management service for special population
|
Healthcare knowledge and skills in health management and holistic health services for children, women, the elderly, and patients with chronic diseases in the community
|
|
1c. Health education service
|
Education skills with knowledge of disease prevention and health promotion
|
|
1d. Management of infectious patients
|
Skills in managing people with infectious diseases such as tuberculosis and AIDS in the community
|
|
1e. Rehabilitation service
|
Skills in developing the rehabilitation medical plan and providing rehabilitation knowledge for patients with physical impairments in the community
|
|
1f. Disease surveillance
|
Ability to continuously monitor the high-risk population for specific diseases (e.g. hypertension/diabetes/asthma/influenza) in the community
|
|
1g. Referral coordination
|
Coordinated ability to make accurate referrals to level 2 and 3 hospitals based on the patient’s condition and the expertise of the superior hospital specialist
|
|
1h. Using telemedicine system
|
Skills in handling equipment such as telemedicine
|
|
1i. Using two-way referral information system
|
Proficiency in the use of a two-way referral information system
|
|
1j. Online health education
|
Skills in educating patients and their families through information technology tools such as apps
|
|
1k. Online health promotion
|
Skills in helping patients manage their own health using information technology tools such as apps
|
|
1l. Online health guide
|
Skills in providing health guidance for patients and their caregivers using the Internet
|
|
1m. Online information exchange
|
Ability to use the Internet to exchange information
|
|
1n. Understanding and implementation of primary healthcare regulations
|
Achieve in their efforts to ensure that they are aware of and take steps to comply with relevant laws, policies, and regulations
|
|
2. Professionalism
|
2a. Frontier understanding of industry dynamic
|
Accurate and timely understanding of the latest developments of and concepts related to Internet Plus family doctor
|
|
2b. Professional interest and recognition
|
Have a strong interest and enthusiasm in the work of family physicians and be proud of this work
|
|
2c. Industry self-discipline
|
Standardize and regulate your own behaviour and do not violate industry or work rules and regulations
|
|
2d. Pursuit of progress and development
|
Work hard, do not be satisfied with the status quo, and actively learn new knowledge and skills to help yourself improve and develop
|
|
2e. Spirit of service
|
Have the will and determination to serve patients in the community and protect the health of residents
|
|
2f. Respect the patient's right to know and privacy
|
Protect patient privacy and respects the right of patients and their families to know about their conditions
|
|
2g. Collect and process information
|
Have the ability to collect work-related information (the health problems of the local community and other community-based resources and services) promptly and to accurately analyse and process the information
|
|
2h. Work under stress
|
Effectively relieve stress and handle work when facing external pressures and setbacks
|
|
2i. Time management
|
Have the ability to rationally allocate and utilize your time to effectively achieve the goals
|
|
3.Interpersonal communication and teamwork skills
|
3a. Communicate with patients
|
Fully communicate with patients to understand their personal, family, community, and social background
|
|
|
3b. Doctor-patient decision-making
|
Promote and encourage patients’ motivation and initiative and empower patients and their families to participate in and develop treatment plans for self-health needs
|
|
3c. Meet the needs of patients
|
Have the ability to discover the psychological state and needs of patients and residents
|
|
3d. Team communication and collaboration
|
Communicate with, understand, and support team members to serve the team’s goals together
|
|
3e. Actively seek help
|
Seek help and promptly solve problems that cannot be solved independently at work
|
|
3f. Organizational and coordination capabilities
|
Have the ability to allocate resources according to work tasks, and control and coordinate normal operation of activities
|
|
4. Personal traits
|
4a. Patience
|
Patiently respond to the questions and requirements from patients and residents, and resolve them actively
|
|
4b. Empathy
|
Understand the feelings of others, think and deal with the problems from the perspective of patients and residents, and be willing to take the time to care for and understand the patients
|
|
4c. Grittiness
|
The family physician has perseverance and passion for long-term goals
|
|
4d. Influence
|
Have the ability to use professional knowledge and facts to persuade others and influence their views or decisions
|
|
4e. Responsibility
|
Have a sense of responsibility
|
|
4f. Decisiveness
|
Quickly make judgments and make correct decisions about what happens at work
|
|
Respondents and questions
A total of 450 family physicians were surveyed, with a 93.36% response rate. Eight invalid questionnaires (missing information or incomplete) were excluded. The effective rate of the questionnaire was thus 98.22%. A descriptive analysis of the characteristics of respondents was carried out: 76% were women, 55.4% were in the 30–39 age group, 79% had a bachelor’s degree, 62.2% had worked for more than 10 years, and 68% had a deputy senior title or higher. In China, the professional titles of doctors are junior (physician, physician/resident), intermediate (attending physician), deputy senior (deputy chief physician), and senior (chief physician).
Most of the respondents completed the questionnaire within 15 minutes, with an average completion time of 8 minutes. The average answer score of the 35 statements from the 442 subjects was3.70 (SD = 0.84). Of these, the rate of Strongly Disagree ranged from 0.90% to 5.66%, whereas the rate of Strongly Agree ranged from 8.82% to 31.90% (Table 2).
Table 2. Family physician competency model questions and response characteristics (n=442)
Items
|
Mean
|
SD
|
strongly disagree%
|
strongly agreea%
|
1a. General medical service
|
3.96
|
0.84
|
1.81
|
15.16
|
1b. Health management service for special population
|
3.88
|
0.85
|
2.04
|
15.84
|
1c. Health education service
|
3.82
|
0.73
|
2.26
|
14.71
|
1d. Management of infectious patients
|
3.79
|
0.71
|
2.94
|
14.93
|
1e. Rehabilitation service
|
3.58
|
0.84
|
3.39
|
16.29
|
1f. Disease surveillance
|
3.55
|
0.65
|
3.85
|
13.57
|
1g. Referral coordination
|
3.71
|
0.84
|
2.49
|
14.48
|
1h. Using telemedicine system
|
3.75
|
0.76
|
2.71
|
15.16
|
1i. Using two-way referral information system
|
3.59
|
0.84
|
2.04
|
15.38
|
1j. Online health education
|
4.17
|
1.26
|
1.36
|
27.83
|
1k. Online health promotion
|
3.56
|
0.86
|
3.62
|
16.52
|
1l. Online health guide
|
4.18
|
1.36
|
1.13
|
31.90
|
1m. Online information exchange
|
3.39
|
0.78
|
4.75
|
14.48
|
1n. Understanding and implementation of regulations
|
3.37
|
0.75
|
5.20
|
13.57
|
2a. Frontier understanding of industry dynamic
|
3.41
|
0.71
|
4.30
|
13.35
|
2b. Professional interest and recognition
|
3.42
|
0.74
|
4.52
|
14.48
|
2c. Industry self-discipline
|
4.32
|
1.15
|
0.90
|
30.77
|
2d. Pursuit of progress and development
|
3.54
|
0.77
|
3.39
|
12.44
|
2e. Spirit of service
|
3.77
|
0.76
|
2.71
|
13.35
|
2f. Respect the patient's right to know and privacy
|
3.80
|
0.75
|
2.71
|
14.03
|
2g. Collect and process information
|
3.72
|
0.72
|
2.49
|
12.90
|
2h. Work under stress
|
3.26
|
0.69
|
5.66
|
12.44
|
2i. Time management
|
3.74
|
0.76
|
4.75
|
15.84
|
3a. Communicate with patients
|
4.11
|
1.18
|
1.58
|
30.32
|
3b. Doctor-patient decision-making
|
3.61
|
0.80
|
3.17
|
15.16
|
3c. Meet the needs of patients
|
3.75
|
0.76
|
3.62
|
16.06
|
3d. Team communication and collaboration
|
3.72
|
0.76
|
2.49
|
14.93
|
3e. Actively seek help
|
3.21
|
0.77
|
5.43
|
8.82
|
3f. Organizational and coordination capabilities
|
3.65
|
0.81
|
3.17
|
12.67
|
4a. Patience
|
3.68
|
0.79
|
3.39
|
13.57
|
4b. Empathy
|
3.62
|
0.82
|
2.94
|
12.22
|
4c. Grittiness
|
4.11
|
1.16
|
2.04
|
28.96
|
4d. Influence
|
3.71
|
0.98
|
4.07
|
20.81
|
4e. Responsibility
|
3.75
|
0.84
|
3.17
|
18.10
|
4f. Decisiveness
|
3.23
|
0.74
|
4.98
|
12.44
|
Reliability and Validity Analysis
The reliability analysis of the scale data was carried out with all 35 service competence evaluation items included. The Cronbach’s α coefficient was 0.977, indicating that the scale was very credible. The factor analysis of the scale showed that the KMO value was high, at 0.988, indicating many common factors among the variables. According to Bartlett’s spherical test, the χ2 value was 22917.515 (df=630), p<0.001, suggesting common factors among the correlation matrices, making the scale suitable for factor analysis. The survey scale thus exhibited high structural validity.
Correlations between each of the 35 items and their theorized domain based on the initial family physician competency model were all stronger than correlations between each individual item and the other three domains.
The content validity of the scale was judged according to the Delphi method. The overall authority grade of expert consultation was 0.80, and the response rates of the two rounds of consultation were 93.3% and 86.7%, respectively. Kendall’s coefficient of concordance W was 0.194 (X 2=222.749,P≤0.001). These results indicated that the scale demonstrated good content validity.
Exploratory factor analysis
In this stage, 221 of the 442 respondents were randomly assigned to the EFA group. According to the results for model fit, the four-factor model showed the best fit index; however, its factor structure was chaotic, and only one item was loaded over factor four. The choice of three- or five-factor model was therefore more appropriate from the perspective of structural simplicity. In addition, from the perspective of model fit index, it was more appropriate to select a four- or five-factor model. Five-factor model was retained after comprehensive consideration.
The item combination of the five-factor model was different from that of the original competency model. We labelled Factor 1 as “Health service skills” (Items 1a, 1b, 1c, 1d, 1e, 1f, 1n); Factor 2 as “Online healthcare services” (Items 1g, 1h, 1i, 1j, 1k, 1l, 1m); Factor 3 including 8 items (Items 2a, 2b, 2c, 2d, 2e, 2f, 2g, 2i) in the original dimension “Professionalism” were named ‘Professionalism’. In addition, Factor 4 (including Items 3a, 3b, 3c, 3d, 3f ) and Factor 5 (including Items 4a, 4b, 4c, 4d, 4e) were basically consistent with the dimension’ Interpersonal communication and teamwork skills’ and ‘Personal Traits’, and hence the two factors were named ’Interpersonal communication and teamwork skills’ and ‘Personal Traits’, respectively.
After the exploratory factor analysis, five common factors were extracted including 32 evaluation items, which deviated from the hypothesis model. Therefore, the proposed initial hypothesis model was revised based on the analysis results. The internal consistency test was performed on the extracted common factors, which showed that the internal consistency coefficients of the five common factors were higher than 0.80, indicating that the evaluation model had high reliability (Table 4).
Table 3. Exploratory Factor Analysis Loadings of family physician competency model
Items
|
EFA factors (n = 221)
|
Factor 1
|
Factor 2
|
Factor 3
|
Factor 4
|
Factor 5
|
1a. General medical service
|
0.504*
|
-0.018
|
0.496*
|
-0.010
|
-0.009
|
1b. Health management service for special populat5ion
|
0.643*
|
0.187
|
0.268
|
0.013
|
-0.048
|
1c. Health education service
|
0.668*
|
0.531*
|
-0.022
|
0.104
|
-0.107
|
1d. Management of infectious patients
|
0.520*
|
0.487*
|
0.089
|
0.219
|
0.012
|
1e. Rehabilitation service
|
0.690*
|
0.105
|
0.074
|
0.333*
|
0.143
|
1f. Disease surveillance
|
0.773*
|
0.162
|
-0.006
|
0.343*
|
0.135
|
1g. Referral coordination
|
0.462*
|
0.556*
|
0.261
|
-0.009
|
0.141
|
1h. Using telemedicine system
|
0.291*
|
0.482*
|
0.219
|
-0.048
|
0.158
|
1i. Using two-way referral information system
|
0.197*
|
0.731*
|
0.075
|
-0.107
|
0.008
|
1j. Online health education
|
0.027
|
0.905*
|
-0.085
|
0.012
|
-0.009
|
1k. Online health promotion
|
0.127
|
0.836*
|
0.021
|
0.143
|
-0.016
|
1l. Online health guide
|
-0.052
|
0.965*
|
-0.043
|
0.135
|
-0.157*
|
1m. Online information exchange
|
-0.025
|
0.987*
|
-0.056
|
0.14
|
-0.109
|
1n. Understanding and implementation of regulations
|
0.976*
|
0.049
|
-0.033
|
0.158
|
-0.064
|
2a. Frontier understanding of industry dynamic
|
-0.097
|
0.043
|
0.414*
|
0.008
|
-0.108
|
2b. Professional interest and recognition
|
-0.055
|
0.068
|
0.868*
|
-0.009
|
-0.012
|
2c. Industry self-discipline
|
0.029
|
0.201
|
0.688*
|
-0.016
|
0.013
|
2d. Pursuit of progress and development
|
-0.081
|
0.330*
|
0.343*
|
0.382*
|
0.104
|
2e. Spirit of service
|
0.006
|
0.105
|
0.760*
|
0.159
|
0.219
|
2f. Respect the patient's right to know and privacy
|
-0.005
|
-0.167*
|
0.712*
|
-0.084
|
0.333*
|
2g. Collect and process information
|
-0.109
|
-0.004
|
0.921*
|
0.093
|
0.343*
|
2h. Work under stress
|
-0.104
|
0.214*
|
0.236*
|
0.289*
|
0.372*
|
2i. Time management
|
-0.1
|
0.029
|
0.999*
|
-0.025
|
0.115
|
3a. Communicate with patients
|
0.12
|
0.058
|
-0.069
|
0.796*
|
-0.133
|
3b. Doctor-patient decision-making
|
0.085
|
-0.007
|
0.042
|
0.822*
|
0.266*
|
3c. Meet the needs of patients
|
0.045
|
-0.049
|
0.026
|
0.866*
|
-0.054
|
3d. Team communication and collaboration
|
0.091
|
0.049
|
0.382*
|
0.804*
|
0.159*
|
3e. Actively seek help
|
-0.144
|
-0.005
|
0.159
|
0.159*
|
0.066
|
3f. Organizational and coordination capabilities
|
-0.001
|
0.053
|
-0.084
|
0.897*
|
0.472*
|
4a. Patience
|
0.050
|
-0.072
|
0.093
|
0.115
|
0.848*
|
4b. Empathy
|
0.035
|
-0.019
|
0.289*
|
-0.130
|
0.881*
|
4c. Grittiness
|
-0.066
|
0.064
|
-0.025
|
0.066
|
0.902*
|
4d. Influence
|
-0.109
|
0.073
|
0.058
|
0.266*
|
0.945*
|
4e. Responsibility
|
0.05
|
0.036
|
-0.004
|
-0.054
|
0.290*
|
4f. Decisiveness
|
0.104
|
0.108
|
0.079
|
0.159*
|
0.119*
|
*p<0.05
Table 4 Fitting information indicators for EFA model
Factor
|
χ2
|
df
|
AIC
|
BIC
|
SRMR
|
RMSEA(90% CI)
|
Two -factor
|
1000.805*
|
492
|
8256.088
|
8969.702
|
0.022
|
0.068(0.062,0.074)
|
Three-factor
|
1156.078*
|
525
|
8523.641
|
9125.116
|
0.027
|
0.074(0.068,0.080)
|
Four-factor
|
2163.850*
|
594
|
10128.478
|
10495.480
|
0.069
|
0.109(0.104,0.114)
|
Five-factor
|
1410.474*
|
559
|
8907.160
|
9393.098
|
0.038
|
0.083(0.078,0.088)
|
*p<0.05 AIC: Akaike information criterion; BIC: Bayesian information criterion; SRMR: standardized root–mean–square residual; RMSEA: root–mean–square error of approximation
Confirmatory factor analysis
In this study, the remaining 221 samples were randomly selected for EFA models for CFA. The endogenous latent variables (service competences) was influenced by exogenous latent variables F1, F2, F3, F4, and F5 while these exogenous latent variables were measured by endogenous observational variables such as Items 1a–4e (Table 5). According to the fit results, all fit indexes suggested that the model passed the goodness-of-fit test (non-normed fit index = 0.98, Tucker–Lewis index = 0.91, SRMSR = 0.05, and RMSEA = 0.04). According to the analysis results, the Cronbach’s α coefficients for the scale and each sub-item were greater than 0.9 (F1, Health service skills α = 0.91; F2, Online healthcare services α = 0.94; F3, Professionalism α = 0.92; F4, Interpersonal communication and teamwork skills α = 0.91; Factor 5, Personal traits α = 0.92), indicating that the data were reliable.
Table 5. Factor loading estimates for CFA model and weights
Factors
|
Items
|
Standardized factor load
|
S.E.
|
Absolute influence coefficient
|
Factor1. Health service skills
|
1a. General medical service
|
0.913
|
0.034
|
0.85
|
1b. Health management service for special population
|
0.981
|
0.027
|
0.82
|
1c. Health education service
|
0.82
|
0.023
|
0.77
|
1d. Management of infectious patients
|
0.852
|
0.02
|
0.79
|
1e. Rehabilitation service
|
0.876
|
0.017
|
0.82
|
1f. Disease surveillance
|
0.891
|
0.015
|
0.83
|
1n. Understanding and implementation of regulations
|
0.815
|
0.024
|
0.76
|
Factor 2. Online healthcare services
|
1g. Referral coordination
|
0.862
|
0.018
|
0.8
|
1h. Using telemedicine system
|
0.85
|
0.02
|
0.79
|
1i. Using two-way referral information system
|
0.866
|
0.018
|
0.81
|
1j. Online health education
|
0.827
|
0.022
|
0.77
|
1k. Online health promotion
|
0.814
|
0.024
|
0.76
|
1l. Online health guide
|
0.836
|
0.021
|
0.78
|
1m. Online information exchange
|
0.819
|
0.023
|
0.76
|
Factor 3. Professionalism
|
2a. Frontier understanding of industry dynamic
|
0.837
|
0.021
|
0.78
|
2b. Professional interest and recognition
|
0.828
|
0.022
|
0.77
|
2c. Industry self-discipline
|
0.84
|
0.02
|
0.78
|
2d. Pursuit of progress and development
|
0.85
|
0.019
|
0.79
|
2e. Spirit of service
|
0.91
|
0.012
|
0.85
|
2f. Respect the patient's right to know and privacy
|
0.898
|
0.014
|
0.84
|
2g. Collect and process information
|
0.874
|
0.017
|
0.81
|
2i. Time management
|
0.912
|
0.012
|
0.85
|
Factor 4. Interpersonal communication and teamwork skills
|
3a. Communicate with patients
|
0.909
|
0.012
|
0.85
|
3b. Doctor-patient decision-making
|
0.924
|
0.011
|
0.72
|
3c. Meet the needs of patients
|
0.895
|
0.014
|
0.69
|
3d. Team communication and collaboration
|
0.921
|
0.011
|
0.71
|
3f. Organizational and coordination capabilities
|
0.943
|
0.008
|
0.73
|
Factor 5. Personal Traits
|
4a. Patience
|
0.928
|
0.01
|
0.72
|
4b. Empathy
|
0.86
|
0.018
|
0.67
|
4c. Grittiness
|
0.926
|
0.01
|
0.72
|
4d. Influence
|
0.86
|
0.018
|
0.67
|
4e. Responsibility
|
0.88
|
0.016
|
0.68
|