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Ambulatory care comprises a major and increasingly important part of the U.S. and other countries’ health care sectors. Every year in the U.S., about 80% of the population seeks care at a doctor’s office, amounting to one billion visits. These visits divide almost equally between primary care and specialty clinic organizations. Diagnostic work is part of most ambulatory care, and central to over 40% of patient visits that originate due to a new problem or a flare-up of an ongoing chronic problem. Yet, the risks associated with diagnostic failures have not garnered much attention from health care leaders and policy makers until a recent National Academy of Medicine (NAM 2015) report synthesized research data with the statement that “most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.” This dissertation first reviews organizational theories and measurement challenges relevant to diagnostic safety and quality in the context of ambulatory care, and then presents three papers analyzing specific organizational factors hypothesized to enable or thwart an accurate and timely diagnosis. The first paper targets delayed diagnosis from missed evidence-based monitoring in high-risk conditions (e.g., cancer) within five specialty clinics in an urban publicly funded health system. The second paper analyzes staff-reported office problems that could lead to diagnostic error (e.g., not having test results when needed) in over 900 primary and specialty clinics across the nation. The third paper examines the associations between two types of time pressure (i.e., encounter-level and practice-level), organizational factors, and patient effects including perceptions of missed diagnostic opportunities. The three primary conclusions from this work are 1) organizational vulnerabilities for missed monitoring common to the different clinics included challenges with data systems, communications handoffs, population-level tracking, and patient activities, leading to the development of ‘design seeds’ for context-flexible solutions to improve diagnostic quality; 2) two organizational factors – stage of health information technology (HIT) deployment and patient safety culture are associated with diagnostic-related office problems, and 3) encounter and practice-level time stressors in primary care clinics are associated with perceptions of greater adverse effects on diagnosis and treatment, and worse patients’ experiences of chronic care from the clinic team, respectively, as well as associated with several organizational factors including HIT, patient-centered culture, relational coordination for interdependent teamwork, and leadership facilitation of changes to address frontline practice challenges. Taken together, the dissertation papers also demonstrate the applicability of the NAM Improving Diagnosis Conceptual Framework for research on ambulatory care organizations.

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Stretto—the technique of using a fugue subject in counterpoint with itself, beginning at different time points—occurs prevalently in fugues by J. S. Bach and other baroque composers. This study investigates the formal function of stretto using a corpus analysis of Bach’s use of stretto in the forty-eight fugues of the Well-Tempered Clavier. It documents details regarding each instance of stretto within the corpus and explores connections between these data using graphs and statistical tests, generally as well as in investigation of three specific hypotheses. The conclusion, density, and quantity hypotheses predict that there will be more stretto passages, time-intervals between onsets of adjacent entries in stretto passages will become smaller, and there will be more entries per stretto passage towards the end of the composition. The results do not provide strong evidence supporting any of these hypotheses, and they directly contradict the expectations of the density hypothesis.