Table 3.

Evidence table summarizing implementation facilitators and barriers at the system level

Citation	Target population	Summary points (CFIR construct)
		Facilitators	Barriers
Allen et al. (25)	FQHC and partner American College of Radiology–accredited screening facility	Understanding the patient population (patient needs and resources); Medicare reimbursement (external policy and incentives); frequent, standing meetings (network and communications); relative priority (implementation climate); front end planning the process and flow (planning)	Speaking with radiologists, billing component, registration component, education for staff, required paperwork (relative advantage); complexity of referrals—too many hand offs (complexity); costs required to implement and sustain an intervention, high cost of time, and staff resources (costs); patient trust among current smokers and difficultly providing clear understandable information about the screening process because of low health literacy among population (patient needs and resources); insurance and reimbursement challenges; Medicare requirements (external policy and incentives); missing training piece (planning); numerous competing demands at the organization, leadership—capacity to change (implementation climate)
Copeland et al. (24)	LCS centers that have been designated Screening Centers of Excellence	None provided	Complex CMS regulations including data requirements, complexity of smoking cessation, integrating SDM visits (complexity); insurance and billing issues (external policy and incentives); staffing shortage and turnover (structural characteristics); lack of patient awareness about screening availability (knowledge and beliefs); lack of provider referral (executing)
Eberth et al. (23)	Members of the Society of Thoracic Radiology, an international organization of radiologists	None provided	Lack of reimbursement (external policy and incentives); staffing shortage and turnover (structural characteristics)
Qiu et al. (22)	LCS centers that have been designated Screening Centers of Excellence	The results of research, particularly NLST (evidence strength and quality); front end planning the process and flow (planning); LCS nurse navigators were involved in the development, implementation, and surveillance of many programs (engaging; formally appointed internal implementation leaders)	Costs of the intervention and costs associated with implementing the intervention (cost); transportation, cost for patients (patient needs and resources); not receiving prompt or correct reimbursement from some insurance companies (external policy and incentives); time limitations, chief financial officer or other administrator concerned with cost or other financial concerns (readiness for implementation; available resources and leadership engagement); lack of awareness and knowledge about LCS among the public and physician (knowledge and beliefs); a wide spectrum of adherence to the guidelines, leniency of guidelines (executing)
Watson et al. (21)	FQHCs	Regular meetings to proactively address challenges (network and communications); leadership buy-in and support (readiness for implementation); enthusiastic project champion who conducted internal pilot and provider education; strong champion support at project outset (engaging; champions)	Lack of reimbursement, challenges with individual payer groups (external policy and incentives); tense relationship after screening partner halted project temporarily, inconsistent meeting schedule (networks and communications); low buy-in from leadership; lack of health information technology (readiness for implementation; available resources and leadership engagement); champions left (engaging); rapid rollout leads to numerous implementation challenges simultaneously (executing); minimal communication of lessons learned when expanding to additional clinic sites (reflecting and evaluating)

ACR = American College of Radiology; CFIR = Consolidated Framework for Implementation Research; CMS = Centers for Medicare and Medicaid Services; FQHC = federally qualified health centers; LCS = lung cancer screening; NLST = National Lung Screening Trial; SDM = shared decision making.