building a culture for resilience in finance & control

UNIVERSITY OF GRONINGEN – ANNEMARIJN SCHAAP – MASTER THESIS: BA HEALTH

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Building a culture for resilience in Finance & Control departments

of healthcare organizations: Lessons from the COVID-19 crisis

Annemarijn Schaap (S4550544)

[email protected]

Supervisor: dr. S. Tillema

Co-assessor: prof. dr. G.J. van den Berg

Submission date: 14-06-2021

Wordcount: 12.629

Master Thesis: MSc Business Administration: Health

Faculty of Economics and Business

University of Groningen

Abstract: The COVID-19 epidemic is an external threat to Dutch hospitals, with enormous organizational and financial impact. Costs

increased substantially, while revenues stagnated. Uncertainty made financial strategic management almost impossible, and therefore

dealing with this crisis demands resiliency inside hospital Finance & Control departments to ensure continuity of care. Building resilience

is a continuous process, in which departments learn and develop their resilience capabilities to improve their ability to dea l with and recover

from adverse events Even though organizational culture is suggested to be crucial for building resilience, there is a lack of attention for

studying resilience in relation to cultural context. This paper identifies cultural characteristics that are enabling for building resilience

inside Finance & Control departments in healthcare, in which the studied dimensions of resilience are 1) ability to cope with and adverse

event, and their 2) ability to learn from and adapt to an adverse event. This study conducts a qualitative and interpretive research, by

carrying out a double case study inside the Finance & Control departments of two Dutch University Medical Hospitals. Based on the

results, an additional interview was added with the manager a third Finance & Control department, to reflect more on the generated results.

The study finds positive relationships between, on the one hand characteristics of clan cultures and hierarchical cultures an d on the other

hand the ability to cope with adverse events. Next to that, the study finds positive relationships between, on the one hand characteristics of

clan cultures and adhocracy cultures and on the other hand, the ability to learn from and adapt to adverse events. Based on the results, a

framework is developed in which departmental cultural characteristics are identified that are enabling for each dimension of resilience.

Finance & Control managers can use this framework to build a culture inside their departments that are enabling for building resilience.

The study also reveals a linkage between the COVID-19 pandemic and culture, and explores some initial ideas about this relationship.

Keywords: Uncertainty, resilience, hospitals, departmental culture, financial management, healthcare, CVF, COVID-19

mailto:[email protected]


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1. Introduction

The COVID-19 epidemic forms an external threat to Dutch hospitals, causing disruptions in the provision

of healthcare and financial planning. The epidemic is expected to have a big financial impact on hospital

organizations, which already have thin operating margins and are now on the forefront of this virus outbreak

(Ferneini, 2020). During the first and second waves of the virus outbreak, capacities reached their maximum

and a lot of regular care treatments were canceled or postponed (Van Giessen et al., 2020). Therefore,

reimbursements decreased, while personnel costs and other costs increased (Ferneini, 2020). For hospitals’

Finance & Control departments, these circumstances imply constant adaptation to a changing situation, as

infection rates and prevention measures constantly keep developing. For these departments, dealing with

COVID-19 is a wicked problem, because it entails acting under uncertainty (Feinstein, 2020). Uncertainty

is a situation in which the outcomes of an action cannot be known beforehand (Rittel & Webber, 1973).

The ability to deal with adverse events, change and uncertainty is described by the term ‘resilience’

(Van der Vegt et al., 2015). This paper views building resilience as a continuous feedback process in which

departments learn and develop their resilience capabilities (Duchek, 2020). A resilient organization or

department is able to successfully 1) cope with, 2) learn from and adapt to, and 3) recover from unexpected

events, like the COVID-19 crisis (Sutcliffe & Vogus, 2003; Seville & McManus, 2008; Lee et al., 2013).

This research considers only the first two dimensions of resilience, since the COVID-19 pandemic is still

on-going. Linnenluecke (2017) addresses the gap of studying resilience in relation to the organizational

context, by posing the question if there are organizational structures that promote resilience. The

effectiveness of the resiliency feedback process is expected to be related to organizational culture (Teixeira

& Werther, 2013; Warrick, 2017). For example, cultures in which challenges are considered opportunities

for organizational learning, and in which creativity is stimulated and failure is tolerated, are expected to be

more successful in improving resilience (Barasa et al., 2018). However, extensive research on which

specific cultural characteristics are enabling for building resilience and how these characteristics relate to

the three different dimensions of resilience (i.e. coping, learning/adapting and recovering) is missing. To

improve our understanding, this research aims to explore the proposed relationship between departmental

culture and team resilience more in-depth, by studying hospital Finance & Control departments.

Most of the resiliency literature on hospitals focuses on the medical departments; with topics like

supply and demand management and the continuity of care delivery operations (Rieckert et al., 2021;

Capalongo et al., 2020; Van der Vegt et al., 2015). Capolongo et al. (2020), for example, propose a list of

strategies for resilient hospital operations during the COVID-19 epidemic. The resilience of Finance &

Control departments in healthcare receives less attention, even though the way these departments respond

to unexpected events has a great impact on the financial management, viability and long-term recovery of

UNIVERSITY OF GRONINGEN – J.A. SCHAAP (S4550544) – MASTER THESIS: BA HEALTH

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hospitals, and therefore on the continuity of care (Kuhllar et al., 2020). Knowing how these departments

manage the impact of adverse events is particularly interesting in the Dutch market-based, competitive

system, where the financial viability of healthcare providers is important for continuity of care delivery

(Wammes et al., 2016). Connecting resilience to culture is interesting from the perspective of Finance &

Control departments, since resilience characteristics are often associated with creativity and flexibility,

while most Finance & Control departments have a more formal and advisory role within the organization,

demanding professionalism and objectivity over creativity and innovativeness (Davies et al., 2007).

The COVID-19 epidemic offers a popular context for studying the resilience of organizations

(Verma & Gustafsson, 2020). During this crisis, the resilience of hospital organizations has been tested

immensely, since hospitals play a crucial role in providing essential medical care to COVID-19 patients

(Capolongo et al, 2020). Under normal circumstances, hospitals’ Finance & Control departments look into

the future, to steer the organization into a direction and to provide a financial strategy. However, this

suddenly became very difficult since nobody knew what would happen (Bryce et al., 2020). The first wave

came totally unexpected; hospitals were not prepared and had to cope with the impact of the virus at once

(Bryce et al, 2020). The second (and third) wave came less unexpected, giving hospitals the opportunity for

learning and adapting based on the first wave (Argulian, 2020), although it remained unknown how the

situation would develop from week to week. In the longer-term, hospital organizations need to recover from

the crisis and secure their existence with healthy annual figures. Therefore, the resilience of a Finance &

Control department, contributes to the resilience of the entire hospital during the crisis.

The research question of this study is: ‘How do cultural characteristics affect the ability of Finance

& Control departments of Dutch hospital organizations to be resilient in response to adverse events, like

the COVID-19 crisis, and how are these characteristics related to the first two dimensions of resilience?’.

In this qualitative and explorative double case study, the research question is answered by interviewing

members of hospital Finance & Control departments about the impact and uncertainty of the COVID-19

crisis, their departments’ responses to these circumstances and how these responses are connected to

organizational culture. This research adds to the existing resiliency literature, by improving insights into

cultural characteristics that enable hospital Finance & Control departments to deal with adverse events.

Identifying enabling cultural characteristics and understanding how they are related to building resilience

can help Finance managers and Business Controllers in hospitals to create a more enabling environment for

building resilience. This research is structured as follows. Section 2 contains a theoretical framework in

which potential links between culture and resilience are explored. Section 3 presents the research

methodology, including a conceptual model for answering the research question. In section 4 the results of

the empirical research are shown. Finally, section 5 contains the discussion and conclusion.


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2. Theoretical framework

2.1 Financial management in healthcare

This section starts by sketching the role and position of Finance & Control departments in healthcare

organizations and how COVID-19 has affected these departments. Financial management in healthcare is

not only about budgeting and measuring financial performance, but also about making strategic decisions

in a complex political, regulatory and economic environment (Gapenski, 2007; Nowicki, 2018). Healthcare

managers should incorporate the perspectives of a broad healthcare environment into their advice, including

the perspectives of the organization’s Executive board and medical departments. Next to that, the healthcare

environment is highly regulatory and involves a lot of licensing (Nowicki, 2018).

Important, specifically for hospital Finance & Control departments, is to control costs whilst at the

same time improving the organization’s quality of care provided (Gapenski, 2007; Hammad et al., 2010;

Nowicki, 2018). Next to that, effective revenue cycle management, from appointment scheduling and

patient registration to billing and cash collections at the back end, is a key element of hospital Finance.

Practically all Dutch hospitals are private, nonprofit organizations (Geissler et al. 2011; Wammes et al.,

2016; Groot & Vosselman, 2019). Gapenski (2007) list the financial management goals of nonprofit

hospitals: hospitals must maintain financial viability, generate sufficient income to continue to provide

healthcare services and to invest in new medical technologies, not rely on charity and government funding

for their operations and growth, and strive to provide services to patients as affordable as possible, given

the stated financial requirements.

The role of a Finance & Control department in a healthcare organization usually consists of a range

of activities (Gapenski, 2007; Hammad et al., 2010). First, the evaluation of the financial effectiveness of

current operations and planning for the future. Second, contributing to long-term investment decisions,

which focus on the acquisition of new facilities and equipment. Third, making financing decisions. For

example, the choice between internal and external funds, the use of debt versus equity capital, and the use

of long-term versus short-term debt. Fourth, working capital management or short-term asset management,

to ensure operational effectiveness and reduce costs. Fifth, engaging in contract management, in which

health care organizations must negotiate, sign, and monitor contracts with managed care organizations and

third-party payers. Sixth and last, the management of financial risk.

The COVID-19 crisis imposes an enormous financial risk on hospitals, due to demand shocks and

economic downturn (Kumar et al., 2020). The changes in care delivery and billable services challenge the

ability of hospitals to remain financially solvent (Khullar et al., 2020). The pandemic impacts the cost side

as well as the revenue side. Reimbursements are often volume-based or entail ceiling agreements, meaning

that if the ceiling quantities are not reached, reimbursements will be cut (Wammes et al., 2016). A lot of


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outpatient and elective care was canceled; in the first wave on average 23% percent (Van Giessen et al.,

2020). And this while elective treatments are the most profitable services for hospitals (Khullar et al., 2020).

For instance, Khullar et al. (2020) estimate that US hospitals earn $700 more for elective care services than

for emergency department admissions. Next to that, non-patient revenues, like parking and catering

revenues (McKay & Gapenski, 2009), went down. On the other hand, there are much higher costs related

to additional staff and resources during the pandemic: investments in protection materials, Intensive Care

Unit (ICU) investments, COVID-19 tests for personnel and patients, replacement of sick and quarantined

personnel, extra compensation of employees and research on COVID-19 (Ferneini, 2020). According to the

Dutch Association of Hospitals (NVZ) (NVZ, 2020), care turnover has decreased by an average of 47% in

the first months of 2020 in the Netherlands. Also, costs have increased with approximately € 0.5 to € 2

million per month per hospital in the same time period.

However, in the short term, Dutch hospitals do not need to worry about their financial viability,

since health insurers have promised to neutralize the financial impact of the virus outbreak. In an agreement

between Dutch Health Insurers (ZN), the Dutch Federation of University Medical Centers (NFU) and the

Dutch Association of Hospitals (NVZ), health insurers have offered support measures to hospitals to

compensate the lost income and extra costs of COVID-19 in the year 2020 (NFU, 2020). But challenges

remain for Finance & Control departments of hospitals on dealing with uncertainty, constant changes,

financial planning, investment and financing decisions, short-term asset management, contract management

and billing, risk management, and long-term financial viability and recovery.

All these changes demanded a high level of resilience from hospitals and their Finance & Control

departments. Resilience of hospitals is described as a hospital’s ability to deal with, adapt to and recover

from unexpected events, while continuing to deliver healthcare (Zhong et al., 2014; Rangachari & Woods,

2020). Organizational resilience of hospitals is important, because it is connected to community resilience,

since it influences the deliverance of essential healthcare services to and the recovery of people in the

community (Paturas et al., 2010). Zhong et al. (2014) have developed a framework for evaluating hospital

resilience, with one of the domains being the recovery and adaptation mechanism, which aims at (long-

term) recovery, hospital reconstruction and adaptation, for which financial health is crucial. Fallah-Aliabadi

et al. (2020) also describe administrative resilience, including finance, as a domain of hospital resilience.

Indicators of this part of resilience are management of financial disasters, direct and indirect economic loss,

costs of repair and reconstruction and mitigation budget. Therefore, it can be stated that the resilience of

hospitals’ Finance & Control departments contributes to the resilience of the entire hospital.


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2.2 Resilience

This paper studies the resilience of hospitals’ Finance & Control departments. Departments are subunits of

an organization, consisting of a group of individuals that are responsible for achieving shared goals (Shin

et al., 2016; McEwen & Boyd, 2017; Warrick, 2017; Chapman et al., 2020). The resilience of a department

can be defined as ‘the capacity of a department and its members to manage disruption, to adapt to change,

and to prepare for future work challenges’ (McEwen & Boyd, 2017, p. 259). A department needs to be

able to recognize and adapt collaboratively to unexpected events. This includes monitoring of internal and

external threats to its functioning, responding to disruptions, learning from the experience of disruptive

events and anticipating, to handle future disruptive events (Chapman et al., 2020). Different combinations

of level of disruption, cognitive effort and coordination determine whether this monitoring, responding,

learning and anticipating are successful, and consequently how resilient a department is.

From a financial perspective, an organization is often defined as resilient when it is able to maintain

average revenues during and after dealing with an adverse event (Teixeira & Werther, 2013). However, this

paper adopts a broader perspective on resilience, by viewing it like a dynamic capacity or ability and

continuous feedback process, in which departments constantly adapt and develop to become more resilient

(Duchek, 2020). Resilient departments rely on strong leadership, are aware of their operating environment,

and are able to manage vulnerabilities and to adapt in response to unexpected and rapid change (Lee et al.,

2013). Resilience boosts adaptability and performance, and prepares departments for future challenges or

adverse events (McEwen & Boyd, 2017). Lee et al. (2013) distinguish between planned and adaptive

resilience. Planned resilience or first-order capacity involves the use of predetermined planning and existing

capabilities, and usually occurs before the adverse event has happened (Vogus & Sutcliffe, 2008; Nilakant

et al., 2014). In contrast, adaptive or second-order resilience occurs after the adverse event has happened,

when organizations develop new capabilities in response to situations that are outside of their plans (Vogus

& Sutcliffe, 2008; Nilakant et al., 2014). Resilience is different from risk management, since risk

management is defined as the systematic identification and assessment of potential and actual risks (Mikes,

2011; Singh et al., 2012; Van der Vegt et al., 2015). Risk management is focused on identifying and

decreasing the level of vulnerability to unexpected events, while resilience is focused on dealing with and

recovering from these events. Foss (2020) points out ‘uncertainty’ as a challenge while designing resiliency

strategies to deal with the COVID-19 disruption.

As described in the introduction, two dimensions of resilience are considered in this research: 1)

the ability to cope with an adverse situation, and 2) the ability to learn from that situation and adapt. The

first dimension of resilience, the ability to cope with an adverse event, focuses on the way a department

responds to and deals with the event (Hillmann & Guenther, 2020). An important aspect of this dimension


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is the preparedness, which can also be connected to planned resilience (Prayag et al., 2018). It can also be

assessed by aspects of solution-seeking, which is determined by the ability to respond with fight instead of

flight reactions, the ability to improvise and the ability to consider multiple options (Mallak, 1998). Also

important is decision-making (Prayag et al., 2018), which relates to the decision and leadership structure in

the department, the ability to decide fast and easy, and the role understanding and task coordination of the

members of the department. The last aspect is information access (McEwen & Boyd, 2017), which is

determined by the ability to access appropriate information, the dependence on one or multiple sources

(Hillmann & Guenther, 2020), and the ability to provide the right information in the right places at the right

times (West et al., 2009). The second dimension of resilience is the ability to learn from adverse events and

to adapt. The ability to make effective and easy adjustments in response to the adverse event to be able to

deal with it in a better way, is crucial for this element (Hillman & Guenther, 2020). Next to that, the ability

of department members to take over each other’s roles or tasks and the level of role sharing inside the

department relates to this element (Mallak 1998, Lee et al., 2013). Another aspect is the ability of the

department to reflect on the adverse situation and to draw lessons and insights that can be incorporated in

response to future events (Ducheck, 2020). Figure 1 summarizes this operationalization of resilience.

Figure 1: Operationalization of resilience

Barasa et al. (2018) found that resilience is influenced by organizational culture, as much as by

material resources, preparedness and planning, information management, collateral pathways and

redundancy, governance processes, leadership practices, human capital, and social networks and

collaboration. Building resilience is a continuous process of improving the resiliency domains,

organizations and their departments constantly have to develop the structures and tactics that enable them

to manage competition and environmental change (Mamouni et al., 2014). Enabling cultural characteristics

are crucial for the effectiveness of the continuous feedback loop of resilience in departments (Linnenluecke,


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2017; Barasa et al, 2018; Duchek, 2020). According to Lengnick-Hall (2011) and Warrick (2017) leaders

should not leave building resilience to chance, but design for it as a component of corporate strategy and

strategic management, since resilient departments are able to successfully respond and adapt to challenging

conditions, use these conditions as a source of renewal and even thrive and become better under these

conditions. Teixeira & Werther (2013) suggest that reshaping the culture in departments, can help leaders

to build a higher level of resilience. Organizational culture has already proven to significantly influence the

performance and effectiveness of departments and organizations, by affecting the morale, productivity and

motivation of employees (Shin et al., 2016; Warrick, 2017), but the influence of departmental cultural

characteristics on the dimension of resilience remains understudied (Powley & Cameron, 2020).

2.3 Departmental culture

The term organizational culture refers to the culture of an organization or a department within the

organization and is defined as the environment in which people work and the influence it has on how they

think, act and experience work (Warrick, 2017). Organizational culture is related to shared beliefs, values,

attitudes, behaviors and practices of a department (Davies et al., 2007). Cameron & Quinn (2006) state that

‘an organization’s culture is reflected by what is valued, the dominant leadership styles, the language and

symbols, the procedures and routines, and the definitions of success that make an organization unique’ (p.

17). Shin et al. (2016) describe the culture of a department as a subculture of organizational culture. They

define subcultures as ‘distinct clusters of understandings, behaviors, and cultural forms that identify groups

of people in the organization’ (p. 233). Cultures can differ significantly between departments and

combinations of cultural characteristics can change through time (Teixeira & Werther, 2013; Warrick,

2017). Culture is formed by organizational structures, processes, systems, budgets, leadership styles, team

members, and key internal decision makers (Warrick, 2017). Jin et al. (2013) distinguish between strong

and weak cultures. In strong cultures it is clear what the cultural values and norms are, while they are

unclear, confusing or inconsistent in weak cultures. Strong cultures impact the behaviors and practices of

employees significantly, while weak cultures are difficult to work in because of the lack of expectations

and consistency. Mikes (2011) distinguishes between two opposite cultures that Finance & Control

departments can adopt: quantitative enthusiasm and quantitative skepticism. Quantitative enthusiasm is a

calculative culture that focuses on counting and measuring, while quantitative skepticism is an intuitive

culture that focuses on non-measurable aspects, judgement based on experience and envisionment.

Organizational researchers often use the Competing Values Framework (CVF), designed by Quinn

(1984), to subdivide organizational culture into four types (Maher, 2000; Davies et al., 2007; Ovseiko &

Buchan, 2012; Mandal, 2017). Figure 2 shows the CVF. The horizontal dimension reflects the extent to


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which an organization emphasizes stability and control versus flexibility and discretion; the vertical

dimension reflects the extent to which an organization is focused on its own internal environment and

integration of processes versus the external environment and differentiation. The four quadrants illustrate

four cultural archetypes with their main characteristics: clan culture, adhocracy culture, hierarchical culture

and market culture (Mandal, 2017). Clan cultures are linked to cooperation and human relations, and are

focused on empowerment and open communication (Cameron & Quinn, 2006; Mandal, 2017). Adhocracy

cultures are development orientated, with a focus on continuous improvement and implementation of new

solutions. Hierarchical cultures relate to stability and process control, and tend to systematic problem

solving. Finally, market cultures are often linked to efficiency and productivity, with a focus on creating

external partnerships and enhancing competitiveness.

Figure 2: The Competing Values Framework (Cameron & Quinn,, 2006, p. 46)

An important element within the CVF is leadership style (Maher, 2000). According to Cameron &

Quinn (2006) effective leadership styles tend to match the organization’s culture. For example, clan leaders

tend to adopt the role of mentors or team builders, whereas market leaders are typically hard drivers.

Hierarchical leaders are typical coordinators or organizers, whereas adhocracy leaders tend to adopt the role

of innovator (Maher 2000; Cameron & Quinn, 2006). Research by Davies et al. (2007) on UK hospitals


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showed that hospital Finance managers were likely to overstate hierarchical culture (ordered, uniform,

leader as administrator, bounded by rules and policies, emphasis on predictability) compared to clan culture

(cohesive, participative, leader as mentor, bounded by loyalty and tradition, emphasis om morale), which

might influence the dominant organizational culture within Finance & Control departments.

2.4 Connecting organizational culture and building resilience

Organizational culture is expected to influence the ability to build resilience for three reasons, which are

similar to the reasoning why it influences firm performance (Shin et al., 2016). Strong cultures stimulate

behavioral consistency in the department, which enables the members to make collective effects to achieve

common goals. They also cause department members to perceive and interpret organizational events in a

similar way, which helps them to understand and solve problems together, but could also create biases and

threaten multi-perspective solution-seeking and creativity. Lastly, strong cultures clarify social

expectations, reduce ambiguities and frictions and create a work attitude of meaning and connectedness.

Felipe et al. (2017) study culture and organizational agility. Agility is the capacity for quick, flexible, and

decisive anticipating, initiating, and taking advantage of opportunities and avoiding any negative

consequences of change and is expected to strengthen organizations’ adaptive capacity and therefore

resilience (Harraf et al., 2015). Felipe et al. (2017) find positive relationships between on the one hand clan

cultures, adhocracy cultures and hierarchical cultures, and on the other hand organizational agility. They

do not find a positive relationship between market cultures and organizational agility.

In this thesis, we are interested in how specific cultural characteristics are enabling for building

resilience and how they can be connected to the different dimensions of resilience. Currently, the literature

merely offers some expectations regarding cultural characteristics and their relationships with building

resilience. The few studies that do exist on this topic focus on the relationship between culture and the broad

concept of resilience, and do not distinguish between the different elements of resilience, limiting the

usefulness of the results. Departments might need different cultural characteristics for coping with an

adverse event, than for learning from and adapting to it. For example, cultures in which bureaucratization

and complexity is low and willingness to accept potential problems without denial is high, are more flexible

and might be able to respond and change more rapidly (Felipe et al., 2017; Barasa et al., 2018). Typical

elements of clan culture, like tolerating and sharing mistakes in the department are stated to be crucial for

learning from failure and for adjusting (Frankel et al., 2006; Weick & Sutcliffe, 2007; Barasa et al., 2018).

On the other hand, elements of adhocracy culture, like creativity and room for experimentation are

associated with optimal solution-seeking and adaptation and transformation (Barasa et al., 2018). Intuitive

cultures might be more creative and eager for learning than calculative cultures, while calculative cultures


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might be better in controlling the numbers, which creates stability. Stability, which is an element of

hierarchical culture, could help departments to remain efficient and to control costs, however other elements

of this cultural archetype, like too much focus on formalization and standardization, might restrict

departments’ long-term capability to adapt (Felipe et al., 2017). Elements of market culture, like

accountability and clear expectations in departments are important for individuals to understand their

actions and how those actions will be evaluated (Frankel et al., 2006). For optimal decision-making,

hierarchy could be a restriction, since under adverse circumstances decisions should be taken by the person

with the most expertise, not the person who is highest in the hierarchy (Weick & Sutcliffe, 2007). On the

other hand, hierarchy clarifies responsibilities and tasks, which stimulates fast decision-making.

In summary, there is some initial understanding of the links between cultural characteristics and

the dimensions of resilience, but these links are often ambiguous and contradictory. There has not yet been

an overarching research that combines all the expected relationships and connects them to the first two

dimensions of organizational resilience. Therefore, this study carries out an in-depth research to find out

which cultural characteristics are enabling for each domain of resilience, by studying specifically how

hospital Finance & Control departments have dealt with the COVID-19 epidemic and which cultural

characteristics have supported or restricted them in coping with, and adapting to and learning from the crisis

situation.

3. Methodology

3.1 Research design

This qualitative, double case study research consists of an exploratory and interpretive analysis, to

formulate an in-depth answer to the research question. Qualitative methodology provides a great tool for

studying complex phenomena within their natural contexts and for understanding social processes that

underlie organizational management (Rynes & Gephart, 2004; Baxter & Jack, 2008). The objective of

qualitative research is to gain a contextualized understanding of behaviors, beliefs and motivations

(Hennink et al., 2020). Interpretive research assumes that people create and attach their own meanings to

the world around them, creating intersubjective meanings (Diaz Andrade, 2009). By interpreting and

structuring the meanings that can be derived from the data, this study adopts an inductive approach (Thorne,

2000; Pratt, 2009). The research approach is also rather open-ended, aiming to explore broadly how

elements of culture and different domains of resilience are related in hospital Finance & Control

departments, based on the general relationships that were discussed in the theoretical framework. Due to a

lack of observation possibilities, related to COVID-19, it was hard to assess the culture and resilience of


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departments objectively. Therefore, the focus is on the beliefs that department members have about the

culture in the department and its ability to successfully deal with adverse events (cf. Carmeli et al., 2013).

Figure 3 shows the conceptual model of this research. The goal of this research is to build a

framework that identifies the cultural characteristics that influence each dimension of resilience, which can

help Finance & Control departments in healthcare to design cultures that are enabling for building

resilience.

Figure 3: Conceptual model

3.2 Data collection and analysis

The qualitative data for answering the research question is collected by carrying out interviews with the

members of the Finance & Control departments of Dutch hospitals. Hospitals were selected using selective

sampling (Coyne, 1997). For the validity of the research, it is important that the hospitals and departments

have similar characteristics, like yearly revenues and size. Only Academic Medical Centres were selected

for participation, because of their similarities in terms of higher complexity and additional research costs

relating to COVID-19. In total eight interviews were conducted in three departments. Hospital A and B

were approached for a case study, based on their type, size and the size of their Finance & Control

department. The departments were selected based on their similar roles and tasks within the hospital

organizations. Department A and B were used as two cases, to carry out a comparative case analysis. Four

interviews were carried out in department A and three interviews in department B. To get a more in-depth

perspective on the differences and similarities that were found between cases A and B, an additional


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interview with the manager of department C was added to the research. Department C is not used as a case,

but as an extra reflection on the results found in cases A and B. Department C was selected for being in

between the extremes that were found in hospitals A and B on some aspects, but also for its contrasting

aspects on similarities that were found between hospital A and B. Table 1 displays the participating

departments and their sizes. The interviewees of each hospital department selected themselves for

participation, based on self-selection. Interview participants are Finance & Control managers, Business

Controllers and other Finance & Control employees. An overview of all interview participants, including

their positions and the interview duration, can be found in appendix 1.

Table 1: Overview of participating hospital Finance & Control departments

Department: Size of department:

Department A Planning & Control 17 members

Department B Planning & Control 18 members

Department C Business Control 20 members

The interview questions are semi-structured with open answers, to minimize the influence and bias

of the researcher (Patton, 1999; Cassell et al., 2018). The interview questions were designed based on the

research question and the theoretical framework, and are included in appendix 2. Important themes are

departmental culture, the impact of the COVID-19 pandemic and how departments have responded to it.

Due to circumstances related to the COVID-19, the interviews had to take place through online

communication platforms. The subject-researcher relationship will be interactive and participative,

however, the lack of face-to face-meetings could affect the quality of the social relationship (Cassell et al.,

2018). Data collected from the interviews was labeled by using a combination of inductive and deductive

coding methods (Linneberg & Korsgaard, 2019). The open, axial, and selective coding strategy that was

used is a method that enables researchers to identify, organize, and build theory, by constant comparison of

data, data reduction, and consolidation techniques (Williams & Moser, 2019). Data were categorized and

thematically sorted with open and axial codes that were inductively derived from the case data. The

selective codes were deductively derived from the theoretical framework, based on the most important

themes and concepts. For example departmental culture with aspects like leadership type, norms and values,

shared beliefs and orientation. Other important theoretical concepts were the ability to cope with the

COVID-19 crisis, the ability to learn from the COVID-19 crisis and the ability to adapt to the COVID-19

crisis. The results from the two cases and the additional interview were compared and summarized, to build

a framework regarding the influence of departmental culture on aspects of resilience.


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4. Results

In this section the results of the research are presented. The section starts with some background information

on the two case departments. Next, the cultural aspects that were found in the departments are discussed.

After that, the response of the departments to the COVID-19 pandemic is elaborated on. Subsequently, the

links between departmental culture and resilience are identified and used to build a framework. The study

reveals that there are not only links between culture and resilience, but also between the COVID-19

pandemic and culture. At the end of the section, some initial ideas about this relationship are explored.

4.1 Sketching the scene

The cases studied in this research are department A and B, which are the Finance & Control departments

of hospital A and B. Department A consists of a department Manager, ten Business Controllers, four

Analysts and two Financial Advisors. Department B consists of fifteen Planning & Control employees,

ranging from junior to senior level. The selected departments are all responsible for the financial

management of the hospital divisions or departments, and other hospital-transcending projects. According

to the interviewees, Finance & Control departments have an advisory role and function as a critical eye on

the finances and operations of the hospital divisions.

‘We are concerned with issues like, what it means for the hospital if there are changes in

regulations or financing in the field of healthcare, education or research. What are the financial

consequences and what does it mean for the hospital’s operations?’

– Interviewee B3, Senior Staff Member Planning & Control

Finance & Control departments need to be objective and critical, which makes their role within the

organization rather formal, according to the interviewees. Interviewees tell that their task is to constantly

adapt to the direction in which the organization is going and to advise based on that. Interviewees tell that

Finance & Control departments were historically more about retrospective control and strict compliance

with financial policy, but are nowadays more focusing on collaboration and thinking along with the other

hospital departments. Cooperation and looking for solutions is becoming more important. Interviewee A1

says that this means that Finance & Control departments are now more open to renewal and innovation.

‘Historically, we have been more focused on retrospective control. We are now trying to shift our focus

more towards collaboration, thinking along and being solution-oriented, instead of retrospective control,

while working individually and strictly interpreting the policy.’

– Interviewee A2, Business Controller


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Interviewees state that Finance & Control in healthcare organizations is different from Finance &

Control in commercial organizations. First of all, because making change within a healthcare environment

can take a lot of time and effort, making financial management more difficult, according to interviewee A2.

‘Sometimes it just feels like you're adjusting an oil tanker. To me, that is really the most shocking thing,

how slow things go and how much a hospital could learn from commercial businesses, where, if there is a

chance, it will be on the market only a quarter later, while we always need years for everything. That is

my experience throughout the entire healthcare sector.’


Secondly, different within Finance & Control departments in healthcare organizations is that the patient

always come first and finances second. The mentality in Finance & Control departments in healthcare, is

to ‘put the patient first and to not let the patient become the victim of finances’, tells interviewee B2.

According to interviewee A4, the task of hospital Finance & Control departments in healthcare is to bring

the quality of care, staff shortages and finances together.

‘We also work for the patient. Not literally of course, but we support the medical departments in

providing care to patients properly.’


Thirdly, multiple interviewees indicate that the financial budgets in healthcare have been tight for years.

They tell that hospitals have to deal with increasing patient numbers, while not being allowed to frow in

euro’s. Interviewee A2 states that ‘the disadvantage of a healthcare institution is that it is not like a

commercial party with an infinite amount of money. Therefore, it is more important for Finance & Control

departments to look for solutions, use creativity, and to get people on board.’.

In healthcare the budgets are limited, but the dreams are endless. So, our role is to advise what is the

most sensible financial policy’.


4.2 Departmental culture

Although the roles of departments A and B within the hospital organizations are quite similar, they both

have very diverse departmental cultures. In both department characteristics of all four cultural archetypes

(i.e. clan, hierarchy, adhocracy, market) can be found, however in both departments another cultural


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archetype is the predominant one. This section will give an overview of both departments and their cultural

characteristics.

4.2.1 Department A

Department A is a diverse team in terms of expertise, areas of interest and educational level, and consists

of a lot of young and ambitious people, creating a flexible, multi-perspective environment. The culture in

the department is described as safe and open by the interviewees.

‘Everyone calls each other at the slightest, to spar about things for a few minutes, both for informal

topics as for content-related topics, which I really enjoy.’

– Interviewee A1, Business controller

Clan culture is the predominant cultural archetype in department A, with a focus on personal and

team development, open communication and collaboration. Department members characterize the

department culture by its high level of directness, open communication and giving feedback. Interviewee

A4 tells that Business Controllers are specifically selected by management, based on their ability to be

objective, outspoken and critical. Critical thinking and giving feedback is considered important within the

department, resulting in a strong culture with strong opinions. Interviewees indicate that sharing those

opinions and having open discussions is stimulated to deliver a better product. Reflection on team roles and

teambuilding is considered important within department A, which is a typical characteristic of clan culture.

Interviewees tell that they give each other feedback on communication and team roles. However, reflection

and learning on the field of content-related themes, processes or working methods, corresponding with

aspects of adhocracy culture, does not happen very often according to the interviewees.

‘We reflect a lot on team roles, but I think there is still room for improvement in terms of

reflection on products. For example, for the business cases we advise on, we do not have a general rule

about how to write good advice. I personally think that it depends on the controller what the quality of the

advice is. I think that we should aim for a certain level of quality or at least a few topics that you include

in your advice. So, I think that we should reflect more on topics like that.’


The culture of department A also shows some characteristics of market culture, like the importance of

responsibility and accountability. Interviewee A1 tells that failing deadlines and making mistakes is not a


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problem, as long as department members communicate openly and honestly about it, but also that the

manager of department A demands a lot of responsibility and accountability.

Leadership within department A matches the predominant cultural archetype and corresponds with

the mentor or team builder leadership type of clan culture. The manager of the department mostly coaches

the department members in the field of personal development and team cooperation, rather than on content-

related tasks. All interviewees mention that her primary task is to make sure that the team can do their job

well and to stimulate personal growth. According to them, her only focus is on the coordination of the team

and asking critical questions. Next to characteristics of clan culture, leadership within department A also

shows characteristics that correspond with the coordinator or organizer leadership type of hierarchical

culture, with as main aspects focus on coordination and task division. Interviewees argue that the manager

has an important role in dividing tasks and setting priorities. So, the manager of department A seems to be

more of a people manager, and less a content-specific manager, which is experienced as very positive by

the interviewees.

‘For me it is a breath of fresh air, to have a manager who really manages and actually enjoys it.’


So, the most important cultural aspects found in department A are focus on team building,

directness, open communication, leader as mentor and coordinator, and accountability, which are

characteristics that mainly correspond with the clan culture, and with some elements of hierarchical culture,

placing department A towards the left side of the CVF.

4.2.2 Department B

Department B consists of many member that have been part of the department for a very long time, and

have therefore seen a lot of the organization and resulting in a high level of accumulated expertise and

knowledge, according to the interviewees.

Adhocracy culture is the predominant cultural archetype in department B, with a focus on content-

related development and on continuous improvement. Department B is very strong in reflecting on content-

related issues and processes. Every week the department members discuss their successes, astonishments

and improvement actions, which is a method that has been developed as a part of the project ‘together for

the patient’. This project focuses on how to learn from mistakes and how to have an open discussion about

successes and astonishments, to improve patient care. It started in the medical departments, but has been

rolled out in the support departments as well. Department members indicate that they help each other with


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problems and improvement actions, with their own background and expertise, by discussing how to handle

them. It helps the department members to learn from mistakes and to share lessons learned, or as interviewee

B2 puts it, ‘a problem shared is a problem halved’.

´When mistakes are made, we look into why it went wrong to learn for the next time and to make sure it

will not happen again. We also try to learn how to arrange things in such a way that the mistake does not

happen again.´

- Interviewee B3, Senior Staff Member Planning & Control

There are also some cultural aspects present in department B that relate more to clan culture, like

collaboration and focus on personal relationships. Interviewees characterize department B’s culture by its

high level of helpfulness and cooperation. Department members say they are very involved with each other

on a personal level, for example by visiting each other with maternity visits. Reflecting on team roles and

teambuilding, which also is an element of clan culture, is stated not to be very successful in department B,

by the interviewees. Interviewee B1 tells that the department invests a lot in team building, but that it is not

very successful. For example, the department hosts a monthly plenary session to reflect on team roles, ‘but

that is always very forced, because that is the only moment we talk about it’, according to interviewee B1.

Leadership within department B partly matches the predominant cultural archetype and

corresponds with the innovator type of adhocracy culture. Interviewees tell the manager makes sure that

everybody can put in their expertise and creativity, for innovative solution-seeking. Learning and reflecting

on content-related topics is stimulated by the department manager.

‘There is a lot of freedom for your own input. That is what I like so much about our department. It is

thanks to our manager, because it suits him as a person.’


Leadership within department B also shows lots of aspects of the producer leader type, which belongs to

market culture. The manager of department B is very strong on a subject-specific and professional level.

Interviewee B1 and B2 tell that he has been working for hospital B for a very long time and therefore knows

all the ins and outs and has a lot of expertise. The interviewees agree that the manager of department B is

more interested in content-related matters than in management tasks, which makes him not so much of a

people manager, according to multiple interviewees.


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‘He is the perfect manager to go to for substantive matters, but he is extremely busy and difficult to reach,

and therefore has little regard for the people-aspect that a manager should also have.’


So, the most important cultural aspects found in department B are focus on continuous

development, content-related reflection, leader as producer and innovator, and sharing problems to learn

from them, which are characteristics that mainly correspond with adhocracy culture, and with some

elements of market culture, placing department B towards the right side of the CVF.

4.3 COVID-19 from the perspective of the departments

The COVID-19 pandemic posed a lot of challenges on the financial processes of the departments. Financial

management of the organization became almost impossible. The financial impact of COVID-19 was

unknown. According to the interviewees, budgets and other data could not be used, because they were no

longer representative of reality.

‘There was no longer a basis on which to say whether it was going well or bad or whether one should

raise the alarm.’


Activities of department A and B shifted from structural work to COVID-19 related questions. The

departments were less concerned with activities related to the financial strategy and policy of the hospital.

During the first wave there were no business cases for the Business Controllers to advise on, because every

care division was busy managing the crisis and was no longer occupied with finances.

‘The entire hospital was in a panic mode, because the clinics and ICU’s suddenly filled up with COVID-

19 patients. At that moment nobody was concerned with the finances and did whatever was necessary’.


New departments for COVID-19 patients were set up during the crisis, but in the beginning the

registrational and financial settlements were not properly organized yet. A lot of care products were not

registered, like the medical staff from other departments that got transferred to the ICU. The departments

were only able to observe retrospectively what the impact was and how to deal with that, instead of being

able to steer in advance and thinking along. The first year of the pandemic the departments worked very

hard on isolating the COVID-19 costs to create transparency and clarity, as indicated by all interviewees.


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‘Because every day that someone is lying in a bed, it must be recorded, because only then will we receive

money for it. That is how hospitals are funded. So our administration had to be set up accordingly.’


Only after the first panic was over and after it became clear that COVID-19 was not a temporary

situation, questions arose about how to pay for all COVID-19 related activities. According to several

interviewees it makes sense that the financing of the pandemic started later, because the hospital’s priority

is the continuity of care and initially the medical professionals that are needed in financial arrangements

were focused on patient care. The Finance & Control had to provide insights into the consequences of the

COVID-19 crisis and how to stay transparent and how to map all the extra COVID-19 related costs, like

the additional costs of protective materials, which were subject to a huge price increase due to scarcity, as

one of the examples mentioned by the interviewees.

‘In my heart center, many open heart surgeries were canceled, because you need a place in the

ICU after such a surgery. … So, we had costs that continued, but we no longer had any revenue to match

it. Questions rose, like how do we deal with this? And how can we compensate for it?’


‘What does it mean that on the one hand we deliver less regular care, which means less revenues, but on

the other hand we deliver COVID-19 related costs and therefore we have higher costs. This was an

important issue, particularly in the field of patient care, but also in the field of education and research.’


During the pandemic COVID-19 related projects kept emerging ad hoc, requiring a lot of effort

and time from the departments. For example the continuity arrangement with health insurers, the healthcare

workers bonus and the coverage of additional costs. Some members of department A and B got assigned

special tasks in these projects and had to leave ad hoc. Interviewees of department A indicate that other

department members had to take over tasks without a moment of transfer, which hindered information

access.

‘You did not for 100% have all the information that you would normally have received at a transfer

moment. Next to that, the organization felt the pressure of COVID, so they also didn't have time to give

you all the background information, so you had to rely a lot on half information.’



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The pandemic also changed the registration in terms of production figures, turnover figures and personnel

numbers. Interviewees acknowledge that, initially the departments found it difficult to separate the costs

related to COVID-19 from other costs. It took more than a year before new healthcare products, like for

example video calls with patients, were introduced. Since, it was not clear how the situation would develop,

departments A and B constantly had to adapt. Department B worked hard on providing insights into the

estimated consequences of all scenarios, but that model was under development, forcing the Finance &

Control departments to constantly adapt, which was sometimes experienced as frustrating.

‘If we made a format, a month later the format was already outdated, and we had to make a new format.

… So, it was very unstructured all the time. Well, of course, controllers don't like that at all. So that was

very annoying.’


In later phases of the crisis, departments were able to make much more informed choices. Department B

has worked hard on building scenario’s during the first year on the pandemic, the interviewees of

department B explain, with a program in which fictional departments are designed to run scenarios. This

has helped to make the effects more transparent and to make more informed choices, later on in the crisis.

‘In the first wave, we just closed all the Operating Rooms because we needed that staff. Now we make a

much closer scenario assessment, like, suppose we close one OR, how many nurses will become

available? So, now every choice is much more informed.’


It is still unclear what the long-term effect of the COVID-19 pandemic is on the studied

departments, but department members do expect the crisis to have a long aftermath. It is still hard to map

the impact of the pandemic, while hospitals are still in the middle of it. According to the interviewees, even

when the number of COVID-19 patients has stabilized and society goes back to normal, hospitals and their

Finance & Control departments will still have to deal challenges, like catching up with regular care, the

new patient group of ‘Long COVID’ patients and exhausted medical staff.

‘Do we really have an idea of what happened financially? Or are there still dead corpses in the closet

somewhere?’



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4.4 Culture & resilience

The paper has reviewed the culture in departments A and B and how these departments were affected by

the COVID-19. This research continues by identifying links between departmental culture and resilience.

The categorization of cultural characteristics used in this section was inductively derived from the cases.

This chapter is divided in two parts: 1) culture and the ability to cope with adverse events, and 2) culture

and the ability to learn from and adapt to adverse events. As discussed, the former is related to the way

departments respond to adverse events, whereas the latter is related to how departments learn, reflect and

adapt to be able to deal with adverse events better. Lastly, the results will be reflected on, based on an

additional interview with the manager of department C, and summarized.

4.4.1 Culture & the ability to cope with…

Viewing potential problems as a challenge & acceptance – Department A and B both viewed the

COVID-19 pandemic as a challenge, which has helped them with fast response and solution-seeking.

Interviewees B2 and A1 tell that an unexpected situation presents a lot of challenges, which are seen as

great opportunities to get out of routine tasks. According to the interviewees this demanded a lot of

adaptability and creativity in the departments.

‘I think there's some kind of can-do mentality within our department, that has ensured that we were able

to properly distribute the entire extra workload together and managed to work it out together.’


‘Such an unexpected situation presents a lot of challenges and that is a lot of fun! It asked for a lot of

pioneering, but we as a department like that. It is nice when things are different than usual, so you can

use all of your expertise’


Willingness to accept problems has helped departments to cope the pandemic. For example, department

A’s high willingness to accept potential problems without denial appears from the fact that they quickly

accepted that 2020 was a lost year, by deciding to no longer make any forecasts since they had no insights

into what was going to happen. According to interviewee A3 this has enabled them to focus more on what

was really happening in the departments.

Flexibility – During the COVID-19 pandemic departments had to switch really fast between ad hoc tasks

and issues. Interviewees stress that Finance & Control departments must always be fast in responding to


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what is happening within the organization. According to interviewee B1, Finance & Control departments

are used to dealing with ad hoc cases, high workload and urgency, which forces them to be very flexible

and to think along with possible solutions. Interviewees of department A and B mention that their

experience and flexibility has helped them to respond to the COVID-19 pandemic.

‘I think we could respond so fast and well because we are used to getting those kind of ad hoc cases and

dealing with a high workload and urgency.’


‘Our department was already good at switching quickly. I think that it is part of our duties as Controllers,

to be able to switch quickly, when dealing with different types of problems. A case like COVID-19, that

affects the entire hospital, is a similar problem to what we are normally dealing with, but then like a

thousand times bigger.’


The fact that departments A and B were not used to flexible working before the COVID-pandemic, made

them less flexible in response to the COVID-19 pandemic. Interviewees of department A and B indicate

that they were not prepared for digital working, demanding them to reinvent their ways of working.

‘Most of us did not have any facilities to work from home, so it was all very messy in the beginning.’


Hierarchy & decisiveness – According to the interviewees of both department A and B, the decisiveness

of the managers, which can be connected to hierarchical culture, has played a crucial role in decision-

making during the initial phase of the pandemic. Interviewee A1 states about the manager of department A

that, ‘at the moment she notices that a decision has to be made right away, she does’. Interviewees of

department B confirm the importance of the role of the manager in fast decision-making. Several

interviewees mention that the clarity regarding priorities ensured stability within the department.

‘My manager was very good at prioritizing. He just said, this we do, but that not, and then stood for it.’


Cooperation & intuition – The fact that department A and B had a culture of solution-orientation and co-

operation with the rest of the hospital organization when the pandemic started, has helped them in finding


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solutions together with the rest of the hospital, as indicated by the interviewees. During the COVID-19

pandemic figures were often unavailable or unreliable, making it more important to really observe what

was happening within the hospital departments. Departments that are more focused on quantitative

skepticism and use of intuition, like both department A and B, are therefore more successful in adapting to

the COVID-19 pandemic and too stay in control.

Leader as coordinator – Department A seemed more successful in distributing tasks well than department

B. According to the interviewees, the manager of department A, in her leader role as coordinator relating

to hierarchical culture, was completely focused on management tasks, which has enabled her to

successfully and clearly divide the workload.

‘When one or two colleagues were assigned another task, our manager told everybody that they were not

available for other tasks. She agreed with them that they would not answer their phones. They were

literally out of the air.’


According to interviewees of department B, task division during division and coordination was not very

successful, since the fair distribution of the extra workload of COVID-19 during the COVID-19 pandemic

did not happen, indicates interviewee B1.

‘In practice the redistribution of tasks did not happen. The people dealing with COVID themes were

completely overrun with work, because their regular tasks were not taken over by others.’


Critical attitude, directness, open communication – The critical culture, directness and open

communication, relating to clan culture, were argued to have helped department A with setting priorities

straight and making fast and well-considered decisions. The interviewees argue that the critical nature of

the department has enabled them to be critical about what was reported during the COVID-19 pandemic

and whether it was useful for being in control of the hospital departments.

‘I think that by being critical and open we could make good choices. We could determine which things we

needed to handle, but also which things we could drop. I think it would have been harder to make those

choices, if those open conversations and that critical attitude would not have been there.’



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4.4.2 Culture & the ability to learn from and adapt to…

Adaptability, commitment & personal relationships – Adaptability was argued to be a crucial aspects

for learning from and adapting to the COVID-19 pandemic. Members of department A state had no problem

with role sharing and taking over tasks, because he focus area of the department members rotates every

year, forcing them to be highly adjustable. During the pandemic this has enabled them to take over each

other’s files very well and fast, when department members were transferred to other projects. According

to interviewees of department B, department B was very adaptable whilst working from home, due to their

high level of commitment and strong personal and social relationships with each other. Interviewee B2 tells

that department members were very understanding towards each other. When department members could

not work during the day, for example because of children at home, the department members adjusted their

working hours to the evenings or weekends. Or when children walked around during online meetings,

‘people just waved, accepted the noise and continued’, tells interviewee B2. This adjustability and personal

involvement with each other has enabled the department to tackle the extra workload.

‘One could have said “I have children at home, so I cannot work”, but that is not how it went in our

department. We just started looking for another possible moment to work, because we wanted to work our

hours and do our jobs well.’


External focus – External focus of Finance & Control departments in healthcare was important during the

crisis, according to multiple interviewees. Interviewee B2 tells that department became much more

dependent on what happened at the national level with negotiations between Zorgverzekeraar Nederland

(ZN), Nederlandse Vereniging Ziekenhuis (NVZ) and Nederlandse Federatie UMC’s (NFU) to work out

financial arrangements. So, for departments that were more external focused it was more easy to adapt fast

and successfully to the COVID-19 pandemic.

Leader as innovator & reflection on content-related subjects – Because department B has a content-

related manager, this department was more successful in reflection on content-related matters during the

pandemic, relating to adhocracy culture and innovator leader type, which has made them more efficient in

responding to the issues posed by the departments, as indicated by the interviewees. As stated before, the

department uses a method in which they share successes, astonishments and points of improvements.

Interviewees of department B tell that this method has helped them to constantly reflect on their tasks during

the COVID-19 pandemic. According to the interviewee B3, it was a great way to constantly keep alignment


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with each other about COVID-19 related themes. Problems were discussed centrally to get to the best

solution and to learn from each other’s mistakes, to increase the department's performance.

‘The method has certainly helped us to keep learning and reflecting during the crisis.’


Leader as team builder & reflection of team feeling – The fact that the manager of department A finds

it important to mediate bonding and communication within the department, like a mentor and team builder

leader type of clan culture, has helped the department to stay resilient while adapting to working from home.

Weekly online team meetings and team building activities have enabled department A to constantly reflect

on team-feeling during the COVID-19 situation.

‘The manager constantly tested if everybody is comfortable working from home and able to do their job

properly, which made that we felt very cared for.’

– Interviewee A3, Financial Advisor

4.4.3 Reflection and summary

Department C was selected for an additional interview to reflect on the findings in department A and B.

Hospital C was added to the research for two reasons. The first reason for selection is that the leadership

style inside department C takes a mid-position between the extremes of departments A (i.e. team builder

and coordinator) and B (innovator and producer), with a combination of leader characteristics belonging to

clan, hierarchical, adhocracy and market culture. The manager of department C combines content-related

and management tasks, by stating to be responsible for department overarching subject-specific tasks (i.e.

producer leader type), dividing tasks within the department (i.e. coordinator leader type) and supporting

department members to successfully fulfill their roles (mentor/team builder leader type). Next to that,

continuous development and learning from mistakes are argued to be very important by the manager of

department C (i.e. innovator leader type). The second reason for selection was that, in contrast with

department A and B, department C was used to flexible working and working from home before the

COVID-19 pandemic, which is expected to result in a higher level of flexibility inside the department. The

goal is to observe whether flexibility this has enabled department C to be more faster in responding to

COVID-19.

Just like in department A and B, viewing the COVID-19 pandemic as a challenge has helped

department C to cope with the crisis in its initial phase. The manager of department C states as follows: ‘In


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the beginning we were like, oh this is something new and exciting. Let’s go for it and show what we are

capable of.’. Next to that, the manager of department C confirms that commitment is a cultural characteristic

that was enabling for coping with the COVID-19 pandemic.

‘Because we feel very responsible and involved, we have always looked for the added value that we could

continue to deliver in the hospital as business controllers. Intrinsic motivation to keep learning and to

exert our influence even under these circumstances.’

– Interviewee C1, Manager Business Control

Where the leader type team builder enabled department A to reflect on team development during the

COVID-19 pandemic and the leader type innovator enabled department B to reflect on content-related

issues, combining the leader types has enabled department C to learn and reflect on both aspects during the

pandemic. Interviewee C1 tells that the department constantly reflected on team skills, professional skills

and content-related topics like how to give good advice or how to handle resistance, which enabled them

to adapt to the crisis. Lastly, the manager of department C confirms the expectation that department that

were used to flexible working before the pandemic, had a higher level of flexibility and where therefore

faster in response to the COVID-19 crisis.

‘We already had a lot of experience with working from home. That made us very flexible. We were up and

running very fast to handle the extra workload.’


Based on the results that were found and the reflection on those results, a framework on culture and

resilience can be designed, see figure 4. To summarize the framework, the cultural characteristics that have

proven to be enabling for coping with adverse events inside the studied departments are: viewing problems

as challenges, willingness to accept potential problems, flexibility, hierarchy, decisiveness, leader as

coordinator, critical attitude, directness, open communication, cooperation and intuition, which relate to a

combination of clan culture and hierarchical culture. Elements of hierarchical culture, like decisiveness and

leader as coordinator, helped departments A and B in fast decision-making and ensuring efficiency.

Elements of clan culture, like open communication and intuition, enable departments to combine all

available expertise and different perspectives for effective solution-seeking and information sharing. The

cultural aspects that were enabling for adapting to and learning from adverse events inside the studied

departments are: adaptability, personal commitment, leader as innovator with reflection on content-related

subjects, leader as team builder with reflection on team feeling, and external focus, which relate to a


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combination of clan culture and adhocracy culture. Elements of adhocracy culture, like leader as innovator

and external focus, helped departments with adapting to adverse situations and learning from it on content-

related matters. Elements of clan culture, like leader as team builder and commitment, enable departments

to keep team feeling stable and to reflect on team roles.

Figure 4: The Culture and Resiliency in Healthcare Finances framework

4.4 Initial link: The impact of COVID-19 on culture

The research found not only that departmental culture has shaped how Finance & Control departments in

healthcare have responded to the COVID-19 situation, but also that the COVID-19 pandemic has shaped

the cultures of the Finance & Control departments. Due to the COVID-19 pandemic, working from home

will become more normal. Digital working will change team feeling and relationships within the

departments. Multiple interviewees indicate that the pitfall of working digitally is that it is easy to lose sight

of each other as a team, because it is more difficult to stay in contact with team members. Communication

will be more formal, because all informal contact is gone, according to interviewee A2.

‘You no longer speak to colleagues with whom you do not have common topics.’


In the long-run this cultural change could even influence resilience within departments. Interviewee A3

explains this as follows: ‘You notice that if you have questions you often approach the same persons, where

someone else might be able to answer your question better, because that is where his expertise lies. But


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because you don’t speak to that person very often, you go to the people that you do speak to often.’. Multiple

interviewees state that for Finance & Control departments in hospitals it is important to be connected to the

care divisions, to see what is really happening in the departments. Due to working from home, departments

felt less connected to the medical divisions.

‘A good Business Controller knows what keeps a hospital manager awake at night. Those feelers, which

Business Controllers need to see which direction things are going, are less strong now.


Next to that, departments are expected to become more focused on intuition and tending to

quantitative skepticism. Interviewees stress the increased importance on quantitative skepticism regarding

information management within their departments, during the crisis. Since the numerical figures and

parameters became very meaningless, the department members learned to inform themselves more by non-

numerical information and what was really happening in the hospital. According to the interviewees, there

was more discussion and conversation about how the figures should be interpreted. They also indicate that

the pandemic has also taught the departments to adopt a more realistic approach and not to look too far

ahead. Discussion about the interpretation of results has become much more important. This is expected to

influence departmental culture for the longer term.

‘We have learned to be much more critical about whether we are really in control. Instead of looking at

our dashboard, we learned to really look at what is happening within the organization.’


Lastly, the COVID-19 pandemic has made departments more externally focused. Interviewees

indicate that some department members have been able to develop themselves more on a national level.

‘I think that the network collaboration, the collaboration with other hospitals, general practitioners and

healthcare professionals, has become more important. We have learned that you sometimes actually need

each other in this situation to do things faster and easier.'

– Interviewee C1, Manager Business Control.

These results represent very clear initial links between the COVID-19 pandemic and cultural change within

healthcare Finance & Control departments, and provide a promising basis for more links to be made.


30

5. Conclusion & discussion

Finance & Control departments in healthcare were confronted with great challenges during the COVID-19

epidemic, and had to deal with registrational, financial and other issues. This study has found that culture

played an important role in enabling the studied Finance & Control departments to be resilient in response

to the COVID-19 pandemic, and adds to the pre-existing knowledge on culture and building resilience, by

showing that Finance & Control departments in healthcare need different cultural elements for different

dimensions of building resilience. The cultural characteristics that have proven to be been enabling for

coping with the COVID-19 pandemic, are those that relate to clan culture and hierarchical culture. The

studied departments benefited from hierarchical aspects, like leader decisiveness, for fast decision-making,

coordination and effectiveness. Next to that, characteristics related to clan cultures, like collaboration,

supported effective solution-seeking. The cultural aspects that have been enabling for adapting to and

learning from the COVID-19 pandemic are those that relate to adhocracy cultures and clan cultures. Aspects

of clan culture enabled the departments to successfully reflect on team roles and team feeling.

Characteristics of adhocracy culture, like reflection on content-related outputs, transformation and a more

external focus, proved supporting for this aspect of resilience.

The positive relationship between hierarchical culture and the ability to cope with adverse events,

is contrasting with earlier statements made by Weick & Sutfcliffe (2007) about elements of hierarchical

cultures being restrictive to decision-making. This research shows that elements of hierarchical culture

stimulate clarity of responsibilities and decisiveness, and is therefore enabling for good and fast decision-

making. The framework provided may help Finance & Control managers in healthcare to understand the

importance of building a departmental culture that is enabling for building resilience, and hopes to

encourage managers to build a culture that is combines collaboration and teambuilding (i.e. clan culture)

with decisiveness and coordination (i.e. hierarchy culture) and continuous improvement (i.e. adhocracy

culture). Warrick (2017) proposes ten guidelines for leaders who want to build, reshape and sustain cultures.

Next to that, this study recommends Finance & Control departments in healthcare to continue their

transition towards more cooperation and thinking along with the rest of the healthcare organization, since

this fits with characteristics are enabling for building intuition and resilience. Lastly, this research

recommends healthcare organizations to extend patient-related improvement projects, like the project

'together for the patient' in department B, to the supporting departments, like Finance & Control, more

often, to stimulate continuous improvement and thereby resilience throughout the entire organization.

As stated before in this research, resilience consists not of two, but three dimensions: 1) the ability

to cope with an adverse situation, 2) the ability to learn from that situation and adapt 3) the ability to recover

from the event (Sutcliffe & Vogus, 2003). This study has only studied the first two dimensions of resilience


31

and left out the third dimension (i.e. the ability to recover from adverse events). One aspect of this

dimension is financial stability, focusing the ability to remain financially viable, while dealing with the

adverse event. Other aspects are the understanding of recovery priorities, the belief of department members

of the ability to recover and the expected time of recovery (Lee et al., 2013). Hospitals and their Finance &

Control departments are still in the middle of the COVID-19 crisis, which makes it impossible to investigate

their ability to recover from this adverse event at this moment. There is still a lot of uncertainty regarding

the long-term effects of the pandemic. It would be very useful to investigate the role of departmental culture

on recovering from crisis situations in Finance & Control departments in healthcare, once that the pandemic

has passed and long-term effects are mapped.

This research not only found that departmental culture influences resilience in responding to

adverse events, but also found that the COVID-19 pandemic has shaped departmental culture. For example,

the fact that teams worked from home during the pandemic has changed departmental culture. According

to Barrero et al. (2021) working from home will become much more common after the pandemic, and will

increase from 5% of total workdays to 20% of total workdays. According to Kirkman et al. (2002) building

trust, creating synergy, inclusiveness, involvement and developing teamwork skills are great challenges in

creating successful virtual teams or departments. Lippe & Lippénvi (2020) imply that interactions between

co-workers will become more structured and that tasks of managers will shift more to encouraging

information sharing and assisting with the management of work-family boundaries, which implies an

increased urge for managers with a focus on management tasks. These developments might hinder the

transition of Finance & Control departments in healthcare towards more collaboration and thinking along

with the rest of the organization, since digital working implies that Finance & Control departments will be

less connected to the other departments, making it harder to observe what is really happening inside the

organization. The initial links between the COVID-19 pandemic and departmental culture that were found

provide an interesting basis for further investigation, specifically in the healthcare context where working

from home was not part of the culture before the COVID-19 pandemic.

A limitation of this study is that, due to the COVID-19 lockdown, observations were not possible,

and therefore all conclusions in this research are based on the opinions and beliefs of the interviewees.

Interpretation of the subjects and the researchers regarding aspects of culture and resiliency may have

played a role in interpreting the results (Cassell et al., 2018). It is acknowledged that it is possible for

different researchers and participants to come up with different explanations for the same phenomenon,

since values and meanings are not universal.


32

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Appendices

Appendix 1: Overview of interview participants

Appendix 2: Overview of interview questions


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Appendix 1: Overview of interview participants

Table 2 shows an overview of the nine interview participants. There are four participants from department

A, four participants from department B and one participant from department C. The function of every

interviewee plus the duration of the interview are stated in the overview.

Table 2: Overview of interviews

Department: Interviewee: Function: Interview duration:

A A1 Business Controller 53:47

A2 Business Controller 42:39

A3 Financial Advisor 54:10

A4 Business Controller 44:14

B B1 Senior staff Member Planning & Control 51:27

B2 Senior Staff Member Planning & Control 57:08

B3 Senior Staff Member Planning & Control 45:18

C C1 Manager Business Control 54:14


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Appendix 2: Interview questions

The interview questions are designed as presented in table 3.

Table 3: Overview of interview questions

Interview questions scheme

General Can you introduce yourself? What is your background?

What is your role within the department?

How would you describe your

department?

What is its function within the organization?

What are its tasks?

What is the size of the department?

How many members has the department?

Culture How would you describe culture

within the department?

What is the atmosphere within the department?

What are important norms and values?

How would you describe leadership within the

department?

To what extent is the department’s culture formal or

informal?

To what extent is the department’s culture open or closed?

Which (un)written rules are there?

Are tasks clearly divided?

Are expectations and responsibilities clear?

How does the department deal with mistakes?

How is communication?

To what extent is the department process-oriented or

outcome-oriented?

To what extent is the department risk-loving or risk-

averse?

Other typical characteristics?

Coping

with…

What was the impact of COVID-

19 when it hit in March 2020, and

what was the departmental

response to it?

What happened in the initial phase?

Which challenges presented themselves?

To what extent was the department prepared for a situation

like this?


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To what extent did the department have access to

information to be able to respond well?

What measures did the department take?

What decisions did the department make?

On the basis of what were decisions made?

Did everybody know what he/she had to do?

What aspects of your

departmental culture contributed

to your ability to respond quickly

and effectively in that very early

phase?

Which aspects enabled you to respond quickly?

Which aspects ensured that you could respond well-

informed?

Learning from

and adapting

to…

As a department, what lessons

have you learned about dealing

with the consequences of

COVID-19 since?

What lessons has the department learned from its response

to that first wave?

What adjustments / changes were made?

As a department, what did you do differently in the second

/ third wave compared to the first wave based on what you

had learned?

Are there other things that you as a department have

adjusted during the crisis?

What role did learning from mistakes and reflecting on

actions play within the department?

To what extent were errors or problems discussed

centrally so that everyone could learn from them?

To what extent were the lessons learned / adjustments

made by the department successful in later stages of the

crisis?

Which aspects of your

departmental culture enabled you

to learn from the situation and

adjust?

Which aspects ensured that the department could make

adjustment easily / quickly?

Which aspects ensured a successful learning process?

Recovering Looking back now, what are the

long-term consequences of the

COVID-19 crisis for your

department? How is the

department planning on dealing

with this?

To what extent has the department been able to maintain

its stability?

To what extent has the department been able to adapt

successfully?

Which problems / effects will continue to play a role?

building a culture for resilience in finance & control

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