DDBA 8562 Week 1 Competing Duties Discussion Example

Week 1 Discussion: Employer Instruction and Professional Duty

Two Duties at One Front Desk: Why a Clinic Manager's Duty to Follow the Employer's Cap on New Medicaid Appointments Is Real, Why the Professional Code Creates a Separate Duty the Employer Cannot Switch Off, and Which One Yields

The Instruction and My Position

The operations manager of a composite multispecialty clinic in Ohio is told by the practice's chief executive to cap new Medicaid patient appointments at two a day, because Medicaid pays less than commercial plans. My position is that the manager owes two distinct duties here, one to the employer and one arising from the profession, and that the professional duty creates an obligation the employer cannot cancel by policy.

The First Source: The Employer

Under agency law, an employee acting as the employer's agent owes a duty to act within the authority the employer grants and to comply with the employer's reasonable instructions. The duty appears in the American Law Institute's restatement of the agent's obligations to the principal (American Law Institute, 2006). The cap falls inside it. Deciding which patients a practice will accept, within the law, is an ordinary business decision, and an instruction to limit new patients of one payer is neither illegal on its face nor unusual. The manager who simply refuses has breached a real duty.

The Second Source: The Profession

The code of ethics that binds members of the American College of Healthcare Executives assigns responsibilities in separate sections (American College of Healthcare Executives, 2022): one each for the profession, the people served, the employing organization, its workforce, and the wider community and society. It does not make the duty to the organization primary. Among the responsibilities to the community is working to support access to care for all people. A cap that limits access by payer, rather than by the practice's capacity, engages that responsibility directly.

Freidson (2001) argued that professionalism is a third logic for organizing work, distinct from both the market and bureaucratic management, in which practitioners hold commitments to their field's purposes that do not derive from their employer. On his account, a professional's obligations do not disappear when an employer issues a contrary instruction; they coexist with it.

Which One Yields

The employer's instruction yields in its current form. The manager should not implement a payer-based cap without first raising it formally: asking whether the clinic's capacity, rather than payment rates, could justify any limit, documenting the access concern and taking it to the practice's compliance or ethics process. If the practice then adopts a cap based on capacity across all payers, the manager can follow it. If it insists on a payer-only cap, the manager faces a choice the code does not resolve, but the manager cannot pretend that following the instruction discharges her professional duty.

Question for Classmates

Have you followed an instruction you believed your professional code would not support, and how did you raise it?

Reply to Lena

Lena, you treat the hospital's no-overtime policy as overriding a nurse manager's duty to staff safely. Is that a conflict of two sources, or does the policy itself allow exceptions you did not mention?

Reply to Theo

Theo, you argue the code always prevails. Would you say the same if the instruction concerned office hours rather than access to care?

References

American College of Healthcare Executives. (2022). ACHE code of ethics.

American Law Institute. (2006). Restatement (third) of agency.

Freidson, E. (2001). Professionalism, the third logic: On the practice of knowledge. University of Chicago Press.