War-game a preop clearance ladder by proving each rung has a named owner, a measured age-out, and a reverse path before draft holds start governing every case claim.
Preop clearance ladders fail when "cleared" means a checkbox without a decision artifact, when teams dual-count a draft hold as both pending and live, and when high-risk service lines still pin to one thin clinic desk because the rung inventory is incomplete. The review needs one written inventory of clearance rungs, one owner who can deny a risky shortcut, and a documented consequence when a failed rung ages past the deadline.
Freeze the ladder text
State which case classes the ladder covers, the effective date, which clearance rungs change, how versions are stored, and what happens to cases already in flight. Name the clinics that feel it first and the on-time promises that depend on coherent clearance handling. If the memo mixes a preop clearance ladder with an instrument tray shortage and a sterile processing rewrite, split them.
Write the decision you will make if the war game finds nothing new. Also write the reverse criteria: the missed rung, clinic gap, or case deadline that would force a clearance rollback within a stated window.
| Rung | Owner question | Fail signal |
|---|---|---|
| History gather | Who can reject incomplete packets? | Missing labs past the age-out |
| Risk score | Who can waive a high-risk hold? | Score without a source export |
| Anesthesia review | Who freezes day-of add-ons? | Verbal clear with no ticket |
| Day-of confirm | Who can abort after room assignment? | Case still listed after abort |
Where ladders fray
- A high-risk service line stays soft while the aggregate clearance dashboard stays green.
- Two teams claim the same rung ownership and neither can force a freeze at week end.
- A restore has already left a clinic without a trusted clearance state.
- The primary preop export lags beyond the planned observation window.
- An operator skips a clearance gate because a block cutoff is near.
For each fray point, require detection time, clinic impact, containment, and the authority to force a clearance rollback. Commands and export links belong in the runbook.
Run adversarial passes
Feed Pingpong the ladder memo, the rung exhibits, and seating briefs for perioperative, anesthesia, clinic ops, and nursing. First pass steelmans the ladder. Later passes attack from those seats. Final pass turns surviving objections into phased rung rules, mitigations, or a changed recommendation. Agreement across passes is not proof. Keep the objections that still have evidence gaps.
Pair with the perioperative lead seat, an instrument tray shortage stress test, a sterile processing rewrite, and the OR ops lead seat. More operating decisions live in the war-game decisions hub.
Ship the ladder only when approved and blocked clearance labels can be reproduced from stored preop exports without a verbal override.