Process Improvement in Stanford Hospital's Operating Room Net Present Value (NPV) / MBA Resources

Introduction to Net Present Value (NPV) - What is Net Present Value (NPV) ? How it impacts financial decisions regarding project management?

NPV solution for Process Improvement in Stanford Hospital's Operating Room case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Process Improvement in Stanford Hospital's Operating Room case study is a Harvard Business School (HBR) case study written by Stefanos Zenios, Kate Surman, Elena Pernas-Giz. The Process Improvement in Stanford Hospital's Operating Room (referred as “Instrumentation Operating” from here on) case study provides evaluation & decision scenario in field of Technology & Operations. It also touches upon business topics such as - Value proposition, Decision making, Developing employees.

The net present value (NPV) of an investment proposal is the present value of the proposal’s net cash flows less the proposal’s initial cash outflow. If a project’s NPV is greater than or equal to zero, the project should be accepted.

NPV = Present Value of Future Cash Flows LESS Project’s Initial Investment

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Case Description of Process Improvement in Stanford Hospital's Operating Room Case Study

In June 2004, members of the Material Flow Committee at Stanford Hospital and Clinics were faced with the challenge of implementing important process improvements in the operating room. Though notable progress had been made in the recent past, complaints from surgeons, nurses, and technicians regarding the availability of surgical instrumentation had reached an all-time high. Finding a solution was urgent, but opinions varied widely regarding the best course of action. Some individuals believed that instrumentation sterilization and processing should be adopted as a core competency (and made central to employee training and compensation). Others felt the hospital should invest in additional instruments and information technology to improve efficiencies. A third faction believed that instrumentation issues resulted, in large part, from low morale and a lack of cross-functional camaraderie and teamwork within the operating room. A decision had to be made to devote Stanford's limited time and resources to the solution that would have the greatest, most immediate impact on its operating room effectiveness.

Case Authors : Stefanos Zenios, Kate Surman, Elena Pernas-Giz

Topic : Technology & Operations

Related Areas : Decision making, Developing employees

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Calculating Net Present Value (NPV) at 6% for Process Improvement in Stanford Hospital's Operating Room Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10014826)	-10014826	-	-
Year 1	3470239	-6544587	3470239	0.9434	3273810
Year 2	3968782	-2575805	7439021	0.89	3532202
Year 3	3970392	1394587	11409413	0.8396	3333618
Year 4	3247927	4642514	14657340	0.7921	2572662
TOTAL			14657340		12712292

The Net Present Value at 6% discount rate is 2697466

In isolation the NPV number doesn't mean much but put in right context then it is one of the best method to evaluate project returns. In this article we will cover -

Different methods of capital budgeting

What is NPV & Formula of NPV,
How it is calculated,
How to use NPV number for project evaluation, and
Scenario Planning given risks and management priorities.

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Capital Budgeting Approaches

Methods of Capital Budgeting

There are four types of capital budgeting techniques that are widely used in the corporate world –

1. Net Present Value
2. Profitability Index
3. Payback Period
4. Internal Rate of Return

Apart from the Payback period method which is an additive method, rest of the methods are based on Discounted Cash Flow technique. Even though cash flow can be calculated based on the nature of the project, for the simplicity of the article we are assuming that all the expected cash flows are realized at the end of the year.

Discounted Cash Flow approaches provide a more objective basis for evaluating and selecting investment projects. They take into consideration both –

1. Timing of the expected cash flows – stockholders of Instrumentation Operating have higher preference for cash returns over 4-5 years rather than 10-15 years given the nature of the volatility in the industry.
2. Magnitude of both incoming and outgoing cash flows – Projects can be capital intensive, time intensive, or both. Instrumentation Operating shareholders have preference for diversified projects investment rather than prospective high income from a single capital intensive project.

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Formula and Steps to Calculate Net Present Value (NPV) of Process Improvement in Stanford Hospital's Operating Room

NPV = Net Cash In Flowt1 / (1+r)t1 + Net Cash In Flowt2 / (1+r)t2 + … Net Cash In Flowtn / (1+r)tn
Less Net Cash Out Flowt0 / (1+r)t0

Where t = time period, in this case year 1, year 2 and so on.
r = discount rate or return that could be earned using other safe proposition such as fixed deposit or treasury bond rate. Net Cash In Flow – What the firm will get each year.
Net Cash Out Flow – What the firm needs to invest initially in the project.

Step 1 – Understand the nature of the project and calculate cash flow for each year.
Step 2 – Discount those cash flow based on the discount rate.
Step 3 – Add all the discounted cash flow.
Step 4 – Selection of the project

Why Technology & Operations Managers need to know Financial Tools such as Net Present Value (NPV)?

In our daily workplace we often come across people and colleagues who are just focused on their core competency and targets they have to deliver. For example marketing managers at Instrumentation Operating often design programs whose objective is to drive brand awareness and customer reach. But how that 30 point increase in brand awareness or 10 point increase in customer touch points will result into shareholders’ value is not specified.

To overcome such scenarios managers at Instrumentation Operating needs to not only know the financial aspect of project management but also needs to have tools to integrate them into part of the project development and monitoring plan.

Calculating Net Present Value (NPV) at 15%

After working through various assumptions we reached a conclusion that risk is far higher than 6%. In a reasonably stable industry with weak competition - 15% discount rate can be a good benchmark.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 15 %	Discounted Cash Flows
Year 0	(10014826)	-10014826	-	-
Year 1	3470239	-6544587	3470239	0.8696	3017599
Year 2	3968782	-2575805	7439021	0.7561	3000969
Year 3	3970392	1394587	11409413	0.6575	2610597
Year 4	3247927	4642514	14657340	0.5718	1857013
TOTAL					10486178

The Net NPV after 4 years is 471352

(10486178 - 10014826 )

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Calculating Net Present Value (NPV) at 20%

If the risk component is high in the industry then we should go for a higher hurdle rate / discount rate of 20%.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 20 %	Discounted Cash Flows
Year 0	(10014826)	-10014826	-	-
Year 1	3470239	-6544587	3470239	0.8333	2891866
Year 2	3968782	-2575805	7439021	0.6944	2756099
Year 3	3970392	1394587	11409413	0.5787	2297681
Year 4	3247927	4642514	14657340	0.4823	1566323
TOTAL					9511968

The Net NPV after 4 years is -502858

At 20% discount rate the NPV is negative (9511968 - 10014826 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Instrumentation Operating to discount cash flow at lower discount rates such as 15%.

Acceptance Criteria of a Project based on NPV

Simplest Approach – If the investment project of Instrumentation Operating has a NPV value higher than Zero then finance managers at Instrumentation Operating can ACCEPT the project, otherwise they can reject the project. This means that project will deliver higher returns over the period of time than any alternate investment strategy.

In theory if the required rate of return or discount rate is chosen correctly by finance managers at Instrumentation Operating, then the stock price of the Instrumentation Operating should change by same amount of the NPV. In real world we know that share price also reflects various other factors that can be related to both macro and micro environment.

In the same vein – accepting the project with zero NPV should result in stagnant share price. Finance managers use discount rates as a measure of risk components in the project execution process.

Sensitivity Analysis

Project selection is often a far more complex decision than just choosing it based on the NPV number. Finance managers at Instrumentation Operating should conduct a sensitivity analysis to better understand not only the inherent risk of the projects but also how those risks can be either factored in or mitigated during the project execution. Sensitivity analysis helps in –

Understanding of risks involved in the project.

What will be a multi year spillover effect of various taxation regulations.

What can impact the cash flow of the project.

What are the key aspects of the projects that need to be monitored, refined, and retuned for continuous delivery of projected cash flows.

What are the uncertainties surrounding the project Initial Cash Outlay (ICO’s). ICO’s often have several different components such as land, machinery, building, and other equipment.

Some of the assumptions while using the Discounted Cash Flow Methods –

Projects are assumed to be Mutually Exclusive – This is seldom the came in modern day giant organizations where projects are often inter-related and rejecting a project solely based on NPV can result in sunk cost from a related project.

Independent projects have independent cash flows – As explained in the marketing project – though the project may look independent but in reality it is not as the brand awareness project can be closely associated with the spending on sales promotions and product specific advertising.

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Negotiation Strategy of Process Improvement in Stanford Hospital's Operating Room

References & Further Readings

Stefanos Zenios, Kate Surman, Elena Pernas-Giz (2018), "Process Improvement in Stanford Hospital's Operating Room Harvard Business Review Case Study. Published by HBR Publications.