The National University Hospital: Overcrowding in the Emergency Department 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 The National University Hospital: Overcrowding in the Emergency Department case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. The National University Hospital: Overcrowding in the Emergency Department case study is a Harvard Business School (HBR) case study written by Muhammad Adnan Zahid Chudhery, Jingui Xie, Mabel C. Chou, Joe Sim. The The National University Hospital: Overcrowding in the Emergency Department (referred as “Emergency Boarding” from here on) case study provides evaluation & decision scenario in field of Technology & Operations. It also touches upon business topics such as - Value proposition, Supply chain.

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 The National University Hospital: Overcrowding in the Emergency Department Case Study

In June 2009, the new chief executive officer at the National University Hospital in Singapore had serious concerns about the hospital's prolonged emergency department boarding time-the time between an emergency doctor's decision to admit a patient and the patient's occupation of a hospital bed. He knew that a prolonged boarding time was one of the leading factors contributing to emergency department overcrowding, which in turn hindered the delivery of high-quality medical care and compromised patient outcomes. The chief executive officer needed to decide what strategy the National University Hospital should adopt to reduce the prolonged emergency department boarding time and how the hospital should execute such a strategy. Muhammad Adnan Zahid Chudhery and Jingui Xie are affiliated with University of Science and Technology of China. Mabel C. Chou is affiliated with National University of Singapore.

Case Authors : Muhammad Adnan Zahid Chudhery, Jingui Xie, Mabel C. Chou, Joe Sim

Topic : Technology & Operations

Related Areas : Supply chain

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Calculating Net Present Value (NPV) at 6% for The National University Hospital: Overcrowding in the Emergency Department Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10011416)	-10011416	-	-
Year 1	3448544	-6562872	3448544	0.9434	3253343
Year 2	3970128	-2592744	7418672	0.89	3533400
Year 3	3949358	1356614	11368030	0.8396	3315957
Year 4	3227444	4584058	14595474	0.7921	2556438
TOTAL			14595474		12659138

The Net Present Value at 6% discount rate is 2647722

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. Payback Period
3. Internal Rate of Return
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. Emergency Boarding 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 Emergency Boarding have higher preference for cash returns over 4-5 years rather than 10-15 years given the nature of the volatility in the industry.

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Formula and Steps to Calculate Net Present Value (NPV) of The National University Hospital: Overcrowding in the Emergency Department

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 Emergency Boarding 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 Emergency Boarding 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	(10011416)	-10011416	-	-
Year 1	3448544	-6562872	3448544	0.8696	2998734
Year 2	3970128	-2592744	7418672	0.7561	3001987
Year 3	3949358	1356614	11368030	0.6575	2596767
Year 4	3227444	4584058	14595474	0.5718	1845302
TOTAL					10442790

The Net NPV after 4 years is 431374

(10442790 - 10011416 )

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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	(10011416)	-10011416	-	-
Year 1	3448544	-6562872	3448544	0.8333	2873787
Year 2	3970128	-2592744	7418672	0.6944	2757033
Year 3	3949358	1356614	11368030	0.5787	2285508
Year 4	3227444	4584058	14595474	0.4823	1556445
TOTAL					9472773

The Net NPV after 4 years is -538643

At 20% discount rate the NPV is negative (9472773 - 10011416 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Emergency Boarding 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 Emergency Boarding has a NPV value higher than Zero then finance managers at Emergency Boarding 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 Emergency Boarding, then the stock price of the Emergency Boarding 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 Emergency Boarding 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.

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.

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.

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 The National University Hospital: Overcrowding in the Emergency Department

References & Further Readings

Muhammad Adnan Zahid Chudhery, Jingui Xie, Mabel C. Chou, Joe Sim (2018), "The National University Hospital: Overcrowding in the Emergency Department Harvard Business Review Case Study. Published by HBR Publications.