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Scenario

Healthy Dynamics is a corporate wellness company that provides a broad range of wellness services for clients seeking to improve the health and wellbeing of their employees. One of the clients of Healthy Dynamics is not happy with their employee wellness program participation rates. Healthy Dynamics is not meeting the contract requirements of 60% engagement, resulting in lost revenue for the company and no return on investment (ROI) for the client. According to the contractual agreement, Healthy Dynamics must pay back the client $200,000,000 if the annual participation percentage is not met. Currently the client’s wellness program includes financial incentives for the employees if they complete the following wellness offerings (health assessment, biometric screening, and telephonic health coaching). The Healthy Dynamics CEO is now foreseeing a need to offer other healthcare services. The CEO has asked the Account Manager to create a business plan focused on increasing revenue and identifying risk that might negatively impact their continued relationship with the client. The Account Manager has tasked you, the Strategic Planning Manager, with preparing an internal memo to present to the CEO and to communicate to your internal team what you are envisioning as a desired future focus area to increase the bottom line for Healthy Dynamics and improve current and future client satisfaction rates.

Instructions

Develop an internal memorandum that includes:

  • A detailed description defining the differences between business planning and strategic planning in healthcare.
  • Identify a specific focus area in the healthcare industry that could increase revenue.
  • Create key questions that you will need to address in the development of your strategic plan for your focus area.

Create a workflow analysis flow chart that includes:

  • A list of healthcare leadership team members (e.g., CEO, Strategic Planning Manager, Account Manager, Marketing Manager, Project Manager, Financial Analyst, etc.,)
  • A comprehensive analysis of each team member’s roles and responsibilities in the development of the strategic plan.
  • Your assignment should include a title page, a reference page, and a minimum of three scholarly sources, two of which must be retrieved from the Rasmussen Library (See attached and choice 2 articles). 

Rubric:

-Detailed description defining the differences between business planning and strategic planning in healthcare in a well-written internal memorandum.

 -Clearly identified a specific focus area in the healthcare industry that could increase revenue in a well-written internal memorandum.

 -Created detailed questions needed to address the development of a strategic plan in a well-written internal memorandum.

 -Created a comprehensive list of healthcare leadership team members in the workflow analysis flow chart.

 -Created a comprehensive analysis of each team member’s roles and responsibilities in the development of the strategic plan.

 -Used and identified three or more credible sources in the memorandum.

 

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Abstract

The Balanced Scorecard (BSC) is a tool for strategic management that is used in many companies and organizations worldwide, both in the public
and private sector. With this purpose it has also been used in healthcare organizations and institutions but there are not many studies on the imple-
mentation of BSC methodology in the day-to-day clinical laboratory. This review shows the strategy for the development of a BSC, which includes
theoretical perspective objectives, as well as some indicators and goals with which the monitoring and quantitative measurement of the achieve-
ments of a strategic plan in a clinical laboratory can be done. Moreover, the results of the indicators allow the prioritization of the initiatives to be
implemented each year.
The methodology for the development of the proposed BSC includes the following steps: definition of theoretical objectives of each of the perspec-
tives most used in the management of a clinical laboratory (customers, financial, internal processes and learning) taking into account the vision and
the organizational model of the laboratory; creation of a strategic map of perspective objectives; definition of the relevant indicators to follow up on
the objectives in a quantitative manner and establishment of the goals. Whether or not the laboratory is a reference laboratory, in which specific and
infrequent analysis and health population programs are performed, is another fact to take into account. In this review a BSC for a reference clinical
laboratory of the Spanish public sector is shown.
Keywords: balanced scorecard; clinical laboratory; management; strategic plan

Received: November 21, 2018 Accepted: February 27, 2019

A balanced scorecard for assessing a strategic plan in a clinical laboratory

Luisa Alvarez*1, Anna Soler1, Leonor Guiñón1, Aurea Mira2

1Quality Unit, Biomedical Diagnostic Center, Hospital Clínic, Barcelona, Spain
2Managing Director, Biomedical Diagnostic Center, Hospital Clínic, Barcelona, Spain

*Corresponding author: [email protected]

Short review

Introduction

Many organizations still present the results ob-
tained from the application of a strategic plan as a
list of achievements reached, sometimes accom-
panied by budget compliance but without using
any other type of analysis, which includes the
study of the impact of their results on the whole.
In this regard, a tool that can be used to track and
obtain quantitative data of the degree of achieve-
ment of the strategic plan’s objectives is the Bal-
anced Scorecard (BSC). The BSC is one of the most
popular performance management tools, which
categorizes the quantifiable objectives of an or-
ganization into four perspectives: financial, cus-
tomer, learning and internal processes (1). For each

objective, indicators and their goals are defined in
order to provide objective and quantitative infor-
mation about the achievements. It was introduced
by Kaplan and Norton in the 1990 and, although it
was originally used in industry, over time its use
has been extended to applications beyond that of
strategic management in this field (2,3). Shortly af-
ter its creation it was introduced for the measure-
ment of performance in healthcare organizations
and institutions in the USA, Canada and in Europe
(4-9). Although the BSC was applied as a tool for
strategic management in laboratory analysis as
early as 2003, few studies have been developed
since then (10). Among them there are those of

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

Salinas, that use indicators of the laboratory pro-
cesses classified according to the four perspectives
cited and of Salas which orders the indicators ac-
cording to the perspective of the internal process
(11-13). It is worth highlighting this shortage of
studies in Spain, despite the fact that in 2008, the
Spanish Society of Laboratory Medicine (SEQCML)
defined Recommendations for the development
of a BSC in the clinical laboratory (14). Moreover,
there are no studies on the implementation of its
use to assess results of the application of a BSC for
monitoring long-term strategic plans.

Given that the BSC’s usefulness for evaluating a
strategic plan in hospital management has been
shown, we hypothesized that the BSC would pro-
vide a useful tool for the Managing Board of clini-
cal laboratories, both to describe the vision and
strategy of their laboratories and to manage im-
plementation and assess the achievements of a
four-year strategic plan. Thus, the aim of this re-
view is to show the strategy that should be fol-
lowed for the development of a BSC, which in-
cludes perspective objectives as well as the indica-
tors and goals with which the monitoring and
quantitative control of the achievements can be
carried out, in the short and long-term of a strate-
gic plan.

Strategy for the development of the BSC

The Managing Board has to take into account the
vision of the clinical laboratory and the manage-
ment model of the organizational structure when
designing a BSC.

The strategy to use includes the following steps:

1. Definition of theoretical perspective objec-
tives

These objectives arise from the answers to the
questions that are formulated considering the four
main perspectives that exist in the management
of a laboratory’s activity:

Customer perspective: How to increase the value
with which customers perceive our activity? What
are their needs and expectations? As some au-
thors have indicated, health institutions have to
devote the greatest efforts to this perspective,

since they are the ultimate recipients of the ac-
tions of improvement and the objectives defined
in all perspectives (8,15). Recipients of the activity
of the clinical laboratory are: citizens, patients and
clinical physicians of the hospital. Furthermore, in
the case of a reference clinical laboratory, physi-
cians or users of other laboratories who send sam-
ples for analysis should be included. As well, in
some clinical laboratories the Ministry of Health of
a country’s Government, that commissions the
laboratory population health programs, will be in-
corporated.

Among the objectives to take into account in this
perspective is the improvement of patient safety
in order to prevent patients from potential risks in
all phases of the analytical process, as Plebani has
shown (16). On the other hand, the clinical labora-
tories that have implemented the ISO 15189 stand-
ard, from the 2012 version have to demonstrate
that they are managing the risks that can affect
patient safety (17).

Financial perspective: How should providers of
financial resources perceive us? How should the
clinical laboratory achieve additional incomes to
those of the Ministry of Health of a country’s Gov-
ernment? Taking into account the comments in
the customer perspective, in healthcare organiza-
tions the objectives of this perspective should go
after those of the customer’s perspective, as indi-
cated by Kaplan and Norton.

Internal process perspective: In which processes
should laboratory staff focus their efforts on and
be excellent in satisfying their customers? Can an
increase in efficacy and efficiency in these pro-
cesses be shown?

Learning perspective: How to achieve a greater
involvement of staff that encourages greater effi-
ciency, higher quality and more innovation? It is an
established fact that in all organizations it is neces-
sary to manage the human factor to a high stand-
ard. Both the one that occupies strategic positions
and the one directly in charge of performing the
analysis, since this factor is what the organization
is based on and that which allows the organization
to achieve excellence. Professionals appreciate the
fact that the Managing Board of a clinical labora-

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

tory is concerned with satisfying all those require-
ments that impact the work environment. There-
fore, a large number of the objectives of the learn-
ing perspective must be aimed at enhancing the
acquisition of greater skills for the personnel and
their professional development, and improving
their motivation and increasing satisfaction.

Finally, the objectives of the strategic plan are in-
cluded in the theoretical perspective’s objectives.
At this point, it has to be mentioned that real ob-
jectives of the strategic plan can have very differ-
ent scopes, particularly in clinical laboratories that
include the activity of all specialties. In such clini-
cal laboratories it can be observed, on the one
hand, that some of the objectives of the strategic
plan (i.e. “extension of existing technologies and
procedures for biomedical diagnosis”) may be in-
cluded in a single perspective (i.e. internal pro-
cess), but is carried out in all Departments. On the
other hand, other objectives of the strategic plan
(i.e. “reorganization of a department”) may be di-
rected to a single department, but initiatives to
achieve the objective may be included in all per-
spectives.

2. Design of the strategic map of the perspec-
tive’s objectives.

The map is developed analysing the cause-effect
relationships of the different objectives among
them. It represents, in graphic form, how the ob-
jectives are linked within their perspective, and
also their relationships between the four perspec-
tives, constituting what is called the alignment of
the objectives. This alignment helps the coher-
ence between them to be understood and shows
how the achievement of some objectives leads to
the achievement of others in the form of a cas-
cade. This strategic map begins with the human
factor, in terms of learning objectives, and then fi-
nally develops into the customer objectives.

3. Definition of indicators and goals of the
perspective’s objectives.

In order to monitor the perspective objectives, rel-
evant indicators and goals have to be designed
which will allow the results obtained to be dis-
played in a quantitative manner. In this regard, it
should be noted that the results of some indica-

tors may assess more than one objective, whether
or not it belongs to the same perspective. Moreo-
ver, in defining the indicators, the organizational
characteristics of the clinical laboratory (if it has
autonomy of management or a system of promo-
tion of professionals, among others) and its type (if
it is a reference clinical laboratory or not) have to
be taken into account. For better management in-
dicators should show, in a clear and understanda-
ble way, to the whole organization the contribu-
tion of the initiatives defined each year in the
achievement of the strategic plan.

The results of the indicators, defined in the cus-
tomer perspective, have to measure the intangible
aspects of the organization as those that demon-
strate the capacity of its professionals to advise
any client or user when they performs a consulta-
tion. As well as, they must show the ability of the
clinical laboratory’s Managing Board to respond to
complaints and incidents that may arise from lab-
oratory performance. In the case of a reference
clinical laboratory, indicators should communicate
the ability to make the laboratory into a leader
based on the excellence of its activity.

One important aspect to consider is the fact that
the results of the objective’s indicators of the BSC’s
financial perspective must be able to demonstrate,
to the entire organization, the leadership capacity
of the clinical laboratory’s Managing Board to
achieve budget compliance. Moreover, the ability
to generate sufficient self-financing will enable
them, on the one hand, to invest in those techno-
logical resources necessary for a better service to
citizens and, on the other hand, to increase the
training of all its professionals.

On the basis of the results obtained, indicators
from the internal process perspective have to
demonstrate the improvement of diagnostic and
analytical process efficiency. Results of these indi-
cators can also demonstrate the greater efficacy of
the analytical process that must be reflected in a
better compliance with the turnaround time and
in obtaining higher quality results. In a reference
clinical laboratory it should also show its capacity
to innovate laboratory medicine.

The results of the learning perspective’s indicators,
in conjunction with those from the perspective of

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

internal processes, must allow the Managing
Board to know at all times the dedication it has,
both to overcome the resistance to change, and to
increase the professional competence of person-
nel in responding to new orientations that the
clinical laboratory will incorporate.

Once the BSC is designed, it is important to inform
the laboratory professionals of the objectives de-
fined. Moreover, as the first results of the indica-
tors are obtained, they must be shown to these
professionals, with values that clearly demonstrate
both their degree of participation and the achieve-
ments derived from their activity. This will syner-
gistically orient their capacity and efforts with
those of the Managing Board in order to obtain
the achievements of the clinical laboratory.

Application of the BSC to assess the four
year strategic plan in a reference clinical
laboratory

The organizational structure of the clinical labora-
tory located in Catalonia (Spain) includes the De-
partments of the different specialties of the labo-
ratory (Pathology, Clinical Biochemistry, Haematol-
ogy, Immunology and Microbiology). In addition
to these Departments, there are two Operational
Areas where automated activity is performed,

both in equipment for analysis based on molecu-
lar absorption spectrophotometry and in immu-
nological techniques (Core Laboratory), as well as
in equipment for carrying out studies based on
molecular biology (Core Molecular Biology). It also
has six transversal support units: client manage-
ment, quality, economic-administrative manage-
ment area, teaching, research and information sys-
tems coordination. The activity performed in the
clinical laboratory each year, more than 7.000,000
determinations or diagnostic studies from a cata-
logue of more than 2800 tests, is carried out by
430 professionals. It is also a reference center for
almost 300 laboratories in Spain which send their
specialised tests to perform. Moreover, in this clini-
cal laboratory different population programs are
carried out, such as newborn screening in the de-
tection of congenital conditions, prenatal screen-
ing tests, histocompatibility studies for solid or-
gan and stem cell transplantation (e.g. HLA typing
and viral serologies for all organ transplants) and
program for early detection of colorectal cancer in
Catalonia.

It has to be stated that the elaboration of a BSC
was facilitated because laboratories have imple-
mented quality management systems (both ISO
9001 and ISO 15189), which allow the Managing
Board of the clinical laboratory to acquire greater

Perspective Objectives

Customers

1. To increase customer satisfaction

2. To improve the image and prestige of the laboratory

3. To improve patient safety

4. To meet the health needs and expectations of the population

Financial
1. Compliance with the strategic budget

2. Generation of sufficient self-financing to meet the objectives of the laboratory mission

Internal Process

1. To innovate laboratory medicine

2. To improve the diagnostic and process efficiency

3. To improve the quality and efficacy of the process and product

Learning

1. To motivate the personnel

2. To increase the training of strategic personnel

3. To increase staff competence

4. To increase internal communication

Table 1. Perspective objectives

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

Figure 1. Strategic map of perspective objectives

knowledge of the organization and its context.
Moreover, the Managing Board uses the annual re-
view report of the quality management system to
know about the improvement actions that are
needed to be implemented, as well as the annual
initiatives that are required (18).

The perspective objectives established for this
clinical laboratory, whose vision is to lead labora-
tory medicine generating and integrating new
knowledge and technological changes and be rec-
ognized as a clinical laboratory of excellence, are
shown in Table 1. In these theoretical objectives,
the annual initiatives defined to achieve the objec-

tives of the four-year strategic plan are classified.
The strategic plan of the laboratory was elaborat-
ed taking into account the guidelines of the Man-
aging Board of the Hospital. Moreover, there is an
alignment between both strategic plans whose
priority areas are: patients (the reason of being of
the Hospital); professionals (their engine) and re-
sources (which make continuity and innovation
possible in care).

In Figure 1 the relationship between the objec-
tives of the same perspective and the relationships
of the objectives between the four perspectives
are shown.

To meet the health
needs and

expectations of the
population

To improve
patient safety

To improve the image
and prestige of the

laboratory

To increase
customer

satisfaction

Generation of
sufficient self-financing
to meet the objectives

of the laboratory
mission

Compliance with
the strategic budget

To improve the
diagnostic and

process efficiency

To improve the
quality and efficacy
of the process and

product

To innovate
laboratory
medicine

To increase
internal

communication

To increase the
training of strategic

personnel
To increase

staff
competence

To motivate
the personnel

Financial perspective: economic
type objectives

Learning perspective: objectives for
the improvement of the human factor

Internal process perspective:
objectives for the improvement
of the efficacy, efficiency and
quality of processes and products

Customer perspective:
objectives representing the
value provided to customer

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

Objectives Indicators Goals

Customer perspective

1. To increase customer satisfaction Degree of satisfaction internal and external customers (assessment of
treatment, reliability of results and overall evaluation)

NSI > 75

Number of complaints received from users = 12 / year

2. To improve the image and
prestige of the laboratory

Degree of external client satisfaction for the advice received in case of
consultation

NSI > 75

Number of publications in scientific journals with impact factor = previous year

3. To improve patient safety Number of incidents reported by Hospital staff due to laboratory performance = previous year

Percentage of turnaround time compliance > 95%

4. To meet the health needs and
expectations of the population

Percentage of population programs that are carried out in the laboratory = previous year

Percentage of tests included in catalogue addressed to the oncological
patient in relation to all the incorporated tests

= 10%

Financial perspective

1. Compliance with the strategic
budget

Percentage of deviation of the budget in consumables material,
personnel and total budget

0 – 1%

2. Generation of sufficient
self-financing to meet the objectives
of the laboratory mission

Annual variation in the number of patients and requests received in the
laboratory

0 – 1%

Annual variation in the billing to external clients 0 – 1%

Customer loyalty: the percentage variation of billing to clients who
requested analysis to the laboratory in the last two years

> 10%

Annual variation in the number of clients: percentage of new clients and
percentage of lost clients

0 – 5%

Internal process perspective

1. To innovate laboratory medicine Percentage of tests incorporated in the Catalog in response to new areas
of knowledge in relation to all incorporated tests

> 10%

2. To improve the diagnostic and
process efficiency

Percentage of tests incorporated to increase the diagnostic efficiency
thanks to technological development of the total test incorporated

> 10%

3. To improve the quality and
efficacy of the process and product

Percentage of determinations with defaults that do not meet the
turnaround time every month of the year

< 3%

Percentage of results of external quality assurance programs to be
reviewed according to the criteria of the organizer

< 3.5%

Percentage of annual initiatives achieved > 80%

Learning perspective

1. To motivate the personnel Degree of professional satisfaction (the assessment of actions dedicated
to improve their quality of life and human and professional promotion)

NSI > 75

Percentage of personnel who have improved their professional category > 10% triannual

Percentage of absenteeism < 2%

2. To increase the training of
strategic personnel

Number of training activities aimed at professionals who carry out
strategic activities

> 1 / year

3. To increase staff competence Percentage of specific training activities to increase professional competence > 10%

Percentage of technicians in a laboratory who can develop the same
activity with respect to the total number of technicians

> 20%

4. To increase internal communication Number of actions carried out to increase the internal communication > 3 / year

NSI – normalized satisfaction index. An NSI between 75 and 85 reflects a good valuation and more than 85 an excellent valuation.

Table 2. Indicators and goals of the customer perspective objectives

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

The indicators and goals of the objectives of each
perspective are shown in Table 2.

Furthermore, that indicators have to be defined
taking into account the objectives and goals of the
Government of the country. In this way, since 2005
in Catalonia, patient safety is one of the main pri-
orities of the Ministry of Health of the Govern-
ment’s objectives. So, in the proposed BSC those
aspects in which the performance of the clinical
laboratory can give rise to incidents in other points
of the Hospital, or those caused by the delay in the
delivery of a result or a diagnostic study, are espe-
cially assessed.

As it can be seen in Table 2, some of the goal’s val-
ues are expressed as NSI (Normalized Satisfaction
Index) which is obtained from a calculation devel-
oped by International Business Machines Corpora-
tion (IBM) that is based on the penalty of the low-
est scores.

NSI = [(Ax0) + (Bx25) + (Cx50)
+ (Dx75) + (Ex100)] / N

Where: A = number of responses with a satisfac-
tion score of 1 (very bad), B = number of responses
with a satisfaction score of 2 (bad), C = number of
responses with a satisfaction score of 3 (regular), D
= number of responses with a satisfaction score of
4 (good), E = number of responses with a satisfac-
tion score of 5 (very good) and N = A + B + C + D + E.

The organizational structure of this reference clini-
cal laboratory, that it is based on management au-
tonomy, allows the Managing Board to promote,
on the one hand, efficiency in the management of
human and technological resources and, on the
other, the dedication of resources to special tests,
which are in development or that are not request-
ed frequently. That is why the objectives of the
strategic plan and its annual initiatives are aimed
at implementing the most cutting-edge services
using the latest technology. Sometimes this in-
cludes the use of the latest large equipment which
allows the automated generation of a large num-
ber of results, or the use of innovative technolo-
gies not generally implemented in the network of
healthcare clinical laboratories. It is important to
note that the results of the indicators of the finan-
cial perspective allow the efficiency of the clinical

laboratory in the budget management approved
by the Hospital Managing Board to be demon-
strated, both in the costs of consumables and
equipment, as well as personnel. Likewise, the
greater efficacy of all internal processes, especially
the strategic planning of the organization and per-
sonnel management processes, will be shown in
the achievement of a larger number of the initia-
tives defined annually.

Furthermore, in this reference clinical laboratory, it
is important to consider the results of the learning
perspective indicator, “Percentage of professionals
who have improved their professional category”,
because they will reflect the effort made by all the
laboratory’s personnel to maintain and improve
their competence and their participatory and col-
laborative spirit.

Concluding remarks

A comprehensive BSC that includes theoretical ob-
jectives for each perspective, as well as indicators
and the goals to be achieved, can be a valid, man-
ageable and simple tool in the clinical laboratory
to monitor and quantitatively measure the degree
of achievement of the objectives of a strategic
plan in those organizations that, due to their com-
plexity, have numerous objectives and each year
define a large number of very different initiatives.

This model of BSC has the particularity of having the-
oretical objectives of perspectives rather than the
original strategic objectives. It is adaptable to any or-
ganizational model and to the resources available.
Yet, like all BSCs, its use allows us to demonstrate the
laboratory’s strategy in carrying out its mission.

The BSC is a useful tool to demonstrate to the hos-
pital Managing Board the effectiveness of the clin-
ical laboratory’s managing board and profession-
als both in achieving the initiatives defined annu-
ally, as well as in the development of the strategic
plan. Moreover, it also shows how it can fulfil its
capacity to generate self-financing that allows it to
carry out initiatives of greater risk oriented to cus-
tomers. The annual results of the indicators allow
us to identify in which perspectives the efforts
have to be prioritized.

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Alvarez L. et al. Balanced scorecard for a strategic plan in a laboratory

Acknowledgments

We thank the Managing Board and all profession-
als of the clinical laboratory for their work and val-
uable contribution.

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doi.org/10.1016/j.labcli.2008.09.007

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ones para la elaboracion de un cuadro de mando int