Table 3.

Inner Setting and Outer Setting Factors That Influence CRC Screening Within Stone Mountain Health Services (SMHS)

Emerging Factors	Specific CFIR Construct (Subconstruct)	Influence on CRC Screening Process	Representative Staff Quotes
Inner setting
Staff report high satisfaction with SMHS as a workplace and its patient-centered mission	Culture	Support	“I like that we are not focused on who can pay and who doesn’t. It doesn’t matter. Everybody is treated the same regardless.” – Staff K
SMHS has initiated other formal and informal efforts to improve screening rates and other health behaviors (eg, Flu-FIT trial, mammogram and PAP logs, clinic-based poster campaign of local people demonstrating healthy habits)	Implementation climate (compatibility)	Support	“It was good that we of course got that education and got that out to a lot of people. So foot traffic. You know we had a lot of people that we only see during flu season.” – Staff M “I do think that the posters in the exam room help because it raises awareness to things that they need to be having checked on.” – Staff Z
SMHS has well regarded processes that support organizational changes (eg, highly active performance Improvement committee and established system for staff training)	Implementation climate (learning climate) Readiness for implementation (leadership)	Support	“And [the Performance Improvement Committee is] made up of a nurse practitioner. It’s made up of our maintenance people. It’s made up of front desk people. So it’s not just providers. That have input to these changes.” – Staff C “We usually do webinars. Which is where the training and most of the trainings is done through the webinars. And everybody at each clinic is able to hear the conversations between others. We have monthly staff meetings.” – Staff D “On a performance improvement committee where all the time discussing ways to improve patient care and [name deleted] has become program manager over that. I really feel like it’s an active committee.” – Staff S
Efficient EMR use is challenging due to slow speed/connectivity, and difficulties in creating reports to track multiple patients	Readiness for implementation (available resources)	Hinder	“Sometimes our system is can be slow, which could be a little bit of the issue as well. It gets you behind. As far as everything. Because once you get behind you know you’re pretty much behind. All day long.” – Staff D
Current protocol is that patients must return FOBT test to clinic instead of mailing to company	Implementation climate (compatibility)	Hinder	“Actually we tell them they can’t mail it because they have to put the specimen in it and we actually have to put a lab requisition with it and work it through like a lab to send it to [lab vendor].” – Staff G
The type of patient appointment impacts the ability to consistently address CRC screening—wellness-type appointments are much more conducive than same-day acute visits	Implementation climate (relative priority; compatibility)	Support/hinder	“[Medicare Wellness Visit] gives us more of an opportunity to reach more because the order automatically goes in with that. And so we just automatically try to give everybody [an FOBT kit] that comes in for those visits.” – Staff G “[Y]ou have a patient with 10 problem list and you get to address the one, the most one that you need to use at this time. And then you end up having to say OK you might have to come another time. But for some of them they don’t come another time.” – Staff T
Outer setting
Insurance access through Medicare (eg, wellness visits) and Medicaid (eg, state expansion) have increased ability to offer and patients to receive CRC screening	External policy and incentives	Support	“I think the biggest thing was the [Medicare] wellness visits, they do on patients. I think that, that’s really helped as far as from a nursing standpoint, my standpoint because it kind of forces you to go into that patient’s health maintenance. To look to see when the last colonoscopy was, to research if, if they’ve had one.” – Staff D “I mean in a lot of ways and we have our sliding fee numbers have gone down because of the Medicaid expansion. So I guess the only drawback is that there are a few that are being taken by certain specialists and things like that.” – Staff F
Support from outside companies for follow-up (eg, Cologuard)	Cosmopolitanism	Support	“Once we get the paper signed and send it to [the Cologuard company]. They’re the ones following up with the patients saying you know have you got that done yet? You need to.” – Staff K
Reporting requirements to external regulators and/or funders increase providers awareness of their screening metrics	External policy and incentives	Support	“But since we have been [distributing Uniform Data Set results to providers] and they’re seeing we have definitely seen improvement our meaningful use came up of each year it’s come up a little bit more.” – Staff F
Poor regional social determinants of health related to poverty, employment, transportation, insurance, interpersonal support systems	Patient needs and resources	Hinder	“Probably most in this area will be transportation that will be their biggest [barrier]. Even though Medicaid now will provide transportation for them.” – Staff A “… elderly patients that are widowed or …kids living farther away, so they don’t really have that support system to kind of encourage or to help bring them, as far as transportation goes to bring him to the doctor. Or the extra money to.” – Staff D “And I hate to say that but I do [delay FIT test]. I’ve done that a couple of times because like if they’re in between jobs and it’s hard. I mean this is a poverty area here. I have some patients a lot of patients who don’t have any income coming in… I may delay a FIT test for six months or so until they’re financially able to do it.” – Staff H
Limited colonoscopy access due to insurance, distance to facilities	Patient needs and resources	Hinder	“I’ve had several Medicare and Medicaid but Medicare suddenly I can’t remember which one they were they couldn’t cross state lines. And that really puts the other problem here when the two major or the three major health centers are all in Tennessee.” – Staff F
Lack of patient compliance when offered or provided with test due to perceptions about CRC screening, cancer screening in general, or other reasons	Patient needs and resources	Hinder	“I would say it helps as far as helping patients understand more, but as far as the compliance goes, I just feel like most of these mountainous people or rural community, I think the belief system is what is what kind of holds them back from being compliant.” – Staff D
Staff members have mixed experiences obtaining results from external health care providers (ie, colonoscopy)	Cosmopolitism	Support/hinder	“And then we also try to get copies of those [colonoscopy] reports. Which is definitely a struggle to get the reports back after we send somebody.” – Staff K “The place that I go will send the results back. You have them the next day. So yeah that kind of makes my choice easy where I go. I want somebody that’s going to be interactive with my provider.” – Staff E
Traits (eg, gender) and the individual experience (eg, family history, symptoms) of patients influence the completion of CRC screening tests	Patient needs and resources	Support/hinder	“I feel like women are a lot more open and follow through with it. Men, and maybe it’s because, in my opinion it’s because we all start with screenings this early, I mean women are kind of desensitized to it because we talk about cervical, we talk about breast we are kind of used to that conversation.” – Staff M “Maybe not even education so much people that are. More financially stable now seem to be more open to preventative medicine than those that are not.” – Staff C