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The primary aim of this research was to investigate the mediating effect of the decision-making structure on the relationship between perceived environmental uncertainty and hospital performance.

Online and manual survey questionnaires were used to collect data in this study. The target population of this study consists of all middle managers within 11 COVID-19 referral hospitals in Surabaya. A total of 189 responses were collected, however, 27 incomplete responses were excluded from the final dataset. Data was analyzed using SEM-PLS.

The study's findings indicate that decision-making structure plays a role in mediating the link between perceived environmental uncertainty and hospital performance assessed via the Balanced Scorecard, highlighting the significance of flexible decision-making processes during uncertain periods. Moreover, based on our supplementary test, respondents' demographic characteristics influence their perceptions of hospital performance.

Hospital administrators can consider the significance of decision-making structures in responding to environmental uncertainties like the COVID-19 pandemic. By fostering adaptable decision-making processes and empowering middle managers, hospitals may enhance their performance and resilience in challenging situations. Additionally, based on supplementary tests, it is found that differences in the perception of the three Balanced Scorecard perspectives imply that hospitals categorized as types A, B, C, and D should prioritize specific areas to improve their overall performance.

This research adds substantial originality and value to the existing body of knowledge by exploring the interplay between decision-making structures, environmental uncertainty, and hospital performance. It contributes to the literature by specifically focusing on the Covid-19 pandemic, a unique and unprecedented global crisis.