Patient Flow at Brigham and Women's Hospital (A) 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 Patient Flow at Brigham and Women's Hospital (A) case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Patient Flow at Brigham and Women's Hospital (A) case study is a Harvard Business School (HBR) case study written by Anita Tucker, Jillian A. Berry. The Patient Flow at Brigham and Women's Hospital (A) (referred as “Brigham Sicu” from here on) case study provides evaluation & decision scenario in field of Technology & Operations. It also touches upon business topics such as - Value proposition, Change management, Organizational structure, Productivity.

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

Case Description of Patient Flow at Brigham and Women's Hospital (A) Case Study

Brigham and Women's Hospital challenged a team of physicians to improve patient flow from the Emergency Department to Intensive Care Units (ICUs). One of the team members, Selwyn Rogers, Director of the Surgical Intensive Care Unit (SICU) at Brigham and Women's Hospital, encountered workarounds by two physicians attempting to transfer their patients to the SICU because the other ICUs were full. Reflecting on the wasted effort and confusion caused by the workarounds, Rogers sent an email outlining the situation to the team. His email generated a negative backlash and chain of defensive emails from involved staff who felt criticized.

Case Authors : Anita Tucker, Jillian A. Berry

Topic : Technology & Operations

Related Areas : Change management, Organizational structure, Productivity

Calculating Net Present Value (NPV) at 6% for Patient Flow at Brigham and Women's Hospital (A) Case Study

Years              Cash Flow     Net Cash Flow     Cumulative    
Cash Flow
Discount Rate
@ 6 %
Cash Flows
Year 0 (10006993) -10006993 - -
Year 1 3463397 -6543596 3463397 0.9434 3267356
Year 2 3971541 -2572055 7434938 0.89 3534657
Year 3 3956772 1384717 11391710 0.8396 3322182
Year 4 3246025 4630742 14637735 0.7921 2571156
TOTAL 14637735 12695351

The Net Present Value at 6% discount rate is 2688358

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.

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. Internal Rate of Return
3. Payback Period
4. Profitability Index

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

Formula and Steps to Calculate Net Present Value (NPV) of Patient Flow at Brigham and Women's Hospital (A)

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 Brigham Sicu 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 Brigham Sicu 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 %
Cash Flows
Year 0 (10006993) -10006993 - -
Year 1 3463397 -6543596 3463397 0.8696 3011650
Year 2 3971541 -2572055 7434938 0.7561 3003056
Year 3 3956772 1384717 11391710 0.6575 2601642
Year 4 3246025 4630742 14637735 0.5718 1855925
TOTAL 10472272

The Net NPV after 4 years is 465279

(10472272 - 10006993 )

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 %
Cash Flows
Year 0 (10006993) -10006993 - -
Year 1 3463397 -6543596 3463397 0.8333 2886164
Year 2 3971541 -2572055 7434938 0.6944 2758015
Year 3 3956772 1384717 11391710 0.5787 2289799
Year 4 3246025 4630742 14637735 0.4823 1565406
TOTAL 9499383

The Net NPV after 4 years is -507610

At 20% discount rate the NPV is negative (9499383 - 10006993 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Brigham Sicu 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 Brigham Sicu has a NPV value higher than Zero then finance managers at Brigham Sicu 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 Brigham Sicu, then the stock price of the Brigham Sicu 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 Brigham Sicu 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 –

What can impact the cash flow of the project.

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

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.

Understanding of risks involved in 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.

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.

References & Further Readings

Anita Tucker, Jillian A. Berry (2018), "Patient Flow at Brigham and Women's Hospital (A) Harvard Business Review Case Study. Published by HBR Publications.