Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges 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 Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges case study is a Harvard Business School (HBR) case study written by Ali Fadil, Celine Bareil, Isabelle Demers. The Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges (referred as “Cardiac Justine” from here on) case study provides evaluation & decision scenario in field of Leadership & Managing People. It also touches upon business topics such as - Value proposition, .

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 Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges Case Study

This case deals with a project to build a hybrid operating room for cardiac surgery at Montreal's Sainte-Justine University Hospital. The case is discussed from the perspective of change management and implementation processes at the personal and organizational levels. The change involved the learning of new practices with state-of-the-art equipment and the collaboration of two medical teams: surgical and cardiology. This initiative, suggested by a cardiologist in 2002, was finally completed in 2010 following several years of fundraising efforts and the departure of several stakeholders. The arrival of a new CEO in 2009 gave fresh impetus to the project. The leaders of the two teams managed the change to the best of their ability, and a Tactical committee was set up to plan activities and prepare the various actors for the change (managers, cardiologists, cardiac surgeons, anesthesiologists, nurses, technologists, etc.). This case study of a successful change reports the perspectives and perceptions of fourteen key actors, including doctors, nurses, managers, administrators, heads of sectors and other units, and the chief executive officer.

Case Authors : Ali Fadil, Celine Bareil, Isabelle Demers

Topic : Leadership & Managing People

Related Areas :

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Calculating Net Present Value (NPV) at 6% for Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10009533)	-10009533	-	-
Year 1	3445272	-6564261	3445272	0.9434	3250257
Year 2	3956247	-2608014	7401519	0.89	3521046
Year 3	3944658	1336644	11346177	0.8396	3312011
Year 4	3229432	4566076	14575609	0.7921	2558013
TOTAL			14575609		12641326

The Net Present Value at 6% discount rate is 2631793

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

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 Cardiac Justine 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. Cardiac Justine 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 Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges

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 Leadership & Managing People 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 Cardiac Justine 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 Cardiac Justine 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	(10009533)	-10009533	-	-
Year 1	3445272	-6564261	3445272	0.8696	2995889
Year 2	3956247	-2608014	7401519	0.7561	2991491
Year 3	3944658	1336644	11346177	0.6575	2593677
Year 4	3229432	4566076	14575609	0.5718	1846438
TOTAL					10427495

The Net NPV after 4 years is 417962

(10427495 - 10009533 )

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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	(10009533)	-10009533	-	-
Year 1	3445272	-6564261	3445272	0.8333	2871060
Year 2	3956247	-2608014	7401519	0.6944	2747394
Year 3	3944658	1336644	11346177	0.5787	2282788
Year 4	3229432	4566076	14575609	0.4823	1557404
TOTAL					9458645

The Net NPV after 4 years is -550888

At 20% discount rate the NPV is negative (9458645 - 10009533 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Cardiac Justine 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 Cardiac Justine has a NPV value higher than Zero then finance managers at Cardiac Justine 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 Cardiac Justine, then the stock price of the Cardiac Justine 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 Cardiac Justine 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 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 can impact the cash flow of the project.

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.

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 Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges

References & Further Readings

Ali Fadil, Celine Bareil, Isabelle Demers (2018), "Implementation of a Hybrid Operating Room for Cardiac Surgery at the Sainte-Justine University Hospital: Collaboration and Change Management Challenges Harvard Business Review Case Study. Published by HBR Publications.