Children's Hospital Oakland: End-of-Life Dilemmas 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 Children's Hospital Oakland: End-of-Life Dilemmas case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Children's Hospital Oakland: End-of-Life Dilemmas case study is a Harvard Business School (HBR) case study written by Arthur A. Daemmrich, Lauren Davis. The Children's Hospital Oakland: End-of-Life Dilemmas (referred as “Hospital Family” 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, Leadership, Organizational culture, Public relations.

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 Children's Hospital Oakland: End-of-Life Dilemmas Case Study

After suffering severe complications from a relatively minor surgery at a California children's hospital in early December 2013, a young teenage girl was declared brain dead. However, to her family, the girl seemed responsive and they refused to accept the hospital's statement that their daughter was deceased. The hospital arranged visits with social workers and other staff in an attempt to help the family understand that their daughter was dead and, after three days, informed the family of its plan to move the teen's body to the morgue. The case quickly became a nationwide media event. The family acquired a noted lawyer to ensure the teen received the care the family thought was needed, while the hospital hired a public relations firm to become the hospital's voice in the issue, a move that might have exacerbated the problem. With such a complex and tragic crisis that rapidly unfolded, should the hospital have a policy in the event that family members disagree with an official medical diagnosis? How could the hospital have managed the aftermath of the teen's death and prevented a media embarrassment? Arthur Daemmrich is affiliated with KU Medical Center.

Case Authors : Arthur A. Daemmrich, Lauren Davis

Topic : Leadership & Managing People

Related Areas : Leadership, Organizational culture, Public relations

Calculating Net Present Value (NPV) at 6% for Children's Hospital Oakland: End-of-Life Dilemmas Case Study

Years              Cash Flow     Net Cash Flow     Cumulative    
Cash Flow
Discount Rate
@ 6 %
Cash Flows
Year 0 (10029501) -10029501 - -
Year 1 3469443 -6560058 3469443 0.9434 3273059
Year 2 3953520 -2606538 7422963 0.89 3518619
Year 3 3946454 1339916 11369417 0.8396 3313519
Year 4 3232767 4572683 14602184 0.7921 2560654
TOTAL 14602184 12665851

The Net Present Value at 6% discount rate is 2636350

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. Payback Period
2. Internal Rate of Return
3. Profitability Index
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. Magnitude of both incoming and outgoing cash flows – Projects can be capital intensive, time intensive, or both. Hospital Family 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 Hospital Family 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 Children's Hospital Oakland: End-of-Life Dilemmas

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 Hospital Family 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 Hospital Family 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 (10029501) -10029501 - -
Year 1 3469443 -6560058 3469443 0.8696 3016907
Year 2 3953520 -2606538 7422963 0.7561 2989429
Year 3 3946454 1339916 11369417 0.6575 2594858
Year 4 3232767 4572683 14602184 0.5718 1848345
TOTAL 10449539

The Net NPV after 4 years is 420038

(10449539 - 10029501 )

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 (10029501) -10029501 - -
Year 1 3469443 -6560058 3469443 0.8333 2891203
Year 2 3953520 -2606538 7422963 0.6944 2745500
Year 3 3946454 1339916 11369417 0.5787 2283828
Year 4 3232767 4572683 14602184 0.4823 1559012
TOTAL 9479542

The Net NPV after 4 years is -549959

At 20% discount rate the NPV is negative (9479542 - 10029501 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Hospital Family 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 Hospital Family has a NPV value higher than Zero then finance managers at Hospital Family 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 Hospital Family, then the stock price of the Hospital Family 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 Hospital Family 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 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 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.

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

Arthur A. Daemmrich, Lauren Davis (2018), "Children's Hospital Oakland: End-of-Life Dilemmas Harvard Business Review Case Study. Published by HBR Publications.