War-game a step-down criteria rewrite by proving each transfer lane has a named owner, a measured age-out, and a reverse path before draft clocks start governing every step-down move.
Step-down criteria rewrites fail when "ready for step-down" means a status without a decision artifact, when teams dual-count a draft clock as both aspirational and live, and when high-acuity ICU lanes still pin to one thin charge nurse because the lane inventory is incomplete. The review needs one written inventory of step-down lanes, one owner who can deny a risky shortcut, and a documented consequence when a failed transfer ages past the deadline.
Write the criteria as a decision artifact
State which ICU classes the rewrite covers, the effective date, which transfer lanes change, how versions are stored, and what happens to patients already in flight. Name the units that feel it first and the capacity promises that depend on coherent step-down handling. If the memo mixes a step-down criteria rewrite with a ventilator capacity cut and a bed flow huddle rule, split them.
Write the decision you will make if the war game finds nothing new. Also write the reverse criteria: the missed lane, bed gap, or patient deadline that would force a step-down rewrite rollback within a stated window.
Failures to surface before go-live
- A high-acuity ICU lane stays soft while the aggregate step-down dashboard stays green.
- Two teams claim the same lane ownership and neither can force a freeze at week end.
- A restore has already left a desk without a trusted transfer state.
- The primary step-down export lags beyond the planned observation window.
- An operator skips a transfer gate because a bed cutoff is near.
For each failure, require detection time, unit impact, containment, and the authority to force a step-down criteria rewrite rollback. Commands and export links belong in the runbook.
Hostile chairs on the transfers
Feed Pingpong the rewrite memo, the lane exhibits, and seating briefs for ICU ops, step-down nursing, bed management, and quality. First pass steelmans the rewrite. Later passes attack from those seats. Final pass turns surviving objections into phased lane rules, mitigations, or a changed recommendation. Agreement across passes is not proof. Keep the objections that still have evidence gaps.
Pair with the ICU ops lead seat, a ventilator capacity cut stress test, a bed flow huddle rule, and a length of stay target. More operating decisions live in the war-game decisions hub.
Ship the rewrite only when approved and blocked transfer labels can be reproduced from stored step-down exports without a verbal override.