Measure # Weight Measure Description Points

Collaborative Meeting Participation: ASPIRE Quality Champion and

Anesthesiology Clinical Quality Reviewer (ACQR) combined attendance at

meetings. Three total meetings with six opportunities for attendance.

6 / 6 Meetings 10

5 / 6 Meetings 5

4 or Less Meetings 0

Attend ASPIRE Quality Committee e-meetings: ASPIRE Quality Champion or

ACQR attendance across six meetings.

5 - 6 / 6 Meetings 5

4 or Less Meetings 0

ACQR/ASPIRE Quality Champion perform data validation, case validation and

submit data by the 3rd Wednesday of each month for January - November and

by the 2nd Wednesday of the month for December. Data must be of high

quality upon submission with >90% of all high priority and required

diagnostics marked as 'Data Accurately Represented.'

10 - 12 / 12 Months 5

9 or Less Months 0

Site Based Quality Meetings: Sites to hold an onsite in-person or virtual

meeting following the three ASPIRE Collaborative meetings to discuss the data

and plans for quality improvement at their site.

3 Meetings 10

2 Meetings 5

1 Meeting 0

Global Warming Footprint (SUS 02): Percentage of cases where carbon dioxide

equivalents (CO2 eq) normalized by hour for cases receiving halogenated

agents and/or nitrous oxide is less than CO2 eq of 2% sevoflurane at 2L FGF =

2.83 kg CO2/hr or the Total CO2 eq is less than 2.83 kg CO2 for the maintenance

period of anesthesia.

(Cumulative score January 1, 2025 through December 31, 2025)

Performance is ≥ 55

Performance is ≥ 45% 15

Performance is ≥ 40% 10

Performance is < 40% 0

Race & Ethnicity: Race and ethnicity variables mapped to updated MPOG

concepts to align with new OMB standards.

All race & ethnicity variables mapped to updated MPOG concepts by December

31, 2025. 10

Race & ethnicity variable mapping not updated to correspond to MPOG

concepts by December 31, 2025. 0

10%

1 10%

2025 Anesthesiology Quality Improvement and Reporting Exchange (ASPIRE)

Collaborative Quality Initiative Performance Index Scorecard

Cohorts 1 - 7

Measurement Period: 01/01/2025 - 12/31/2025

5 25%

25%

35%

4 10%

Measure # Weight Measure Description Points

2025 Anesthesiology Quality Improvement and Reporting Exchange (ASPIRE)

Collaborative Quality Initiative Performance Index Scorecard

Cohorts 1 - 7

Measurement Period: 01/01/2025 - 12/31/2025

Sexual Orientation, Sex, & Gender Identity: All sexual orientation and gender

identity variables in electronic health record extracted and mapped to an

accepted MPOG concept to align with updated OMB standards.

All sexual orientation, sex, and gender identity fields extracted, mapped, and

submitted to MPOG by December 31, 2025. 10

All sexual orientation, sex, and gender identity fields extracted but not yet

mapped and/or submitted to MPOG by December 31, 2025. 5

All sexual Orientation, sex, and gender identity variables not yet included in the

MPOG extract. 0

Site Directed Measure: Site chooses a measure they are performing below

threshold for a process measure or above threshold for an outcome measure

to improve for the year.

(Cumulative score January 1, 2025 through December 31, 2025)

Performance is ≥ 90% for process or ≤5% for outcome, or

shows ≥ 15% improvement (absolute) 25

Performance is ≥ 85% for process or ≤10% for outcome, or

shows ≥ 10% improvement (absolute) 15

Performance is ≥ 80% for process or ≤ 20% for outcome, or

shows ≥ 5% improvement (absolute) 10

Performance is < 80% for process or > 20% for outcome, or

shows < 5% improvement (absolute) 0

8 25%

7 10%

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

2025 Performance Index Scorecard

Measure Explanation: Cohorts 1 – 7 (2015 – 2022 start)

Measure #1: The ASPIRE Quality Champion (or a designated representative who must be an

anesthesiologist) and the Anesthesiology Clinical Quality Reviewer (ACQR), combined, must attend

ASPIRE Collaborative meetings in 2025. There are three total meetings with six opportunities for

attendance:

1. MSQC (Michigan Surgical Quality Collaborative) / ASPIRE Meeting: Friday, April 11, 2025

2. ASPIRE Collaborative Meeting: Friday, July 18, 2025

3. MPOG (Multicenter Perioperative Outcomes Group) Retreat: Friday, October 10, 2025

Measure #2: There will be six Quality Committee e-meetings in 2025. One representative (ASPIRE

Quality Champion or ACQR) must attend the following 2025 meetings:

1. Monday, January 27, 2025

2. Monday, February 24, 2025

3. Monday, May 19, 2025

4. Monday, July 28, 2025

5. Monday, September 22, 2025

6. Monday, November 24, 2025

Measure #3: Maintenance Schedule located on MPOG website in the resources tab of the quality

section. Data must be of high quality upon submission, >90% of all ‘High Priority’ and ‘Required’ diagnostics

marked as ‘Data Accurately Represented.’

Measure #4: The site is expected to schedule a local meeting either in-person or virtually following each

ASPIRE collaborative meeting (see Measure #1 for dates) to discuss site-based and collaborative quality

outcomes with clinical providers at their site. Sites must send the coordinating center the site-based

collaborative meeting report located on the MPOG website in the P4P sub tab of the Michigan hospitals

tab of the quality section.

Measure #5: Sites will be awarded points for compliance with the sustainability measure SUS 02

(cumulative score January 1, 2025, through December 31, 2025). See P4P Scorecard for point

distribution.

Measure #6: Sites will be awarded points for mapping all race and ethnicity variables to updated MPOG

concepts to align with MSHIELD recommendations. Scores will be determined based on submission of at

least one month of data including race and ethnicity variables mapped to updated race and ethnicity

MPOG concepts by the end of December 2025. See P4P Scorecard for point distribution.

Measure #7: Sites will be awarded points for extracting all sexual orientation, sex, and gender identity

variables available in the electronic health record and mapping to updated MPOG concepts to align with

MSHIELD recommendations. Scores will be determined based on submission of at least one month of

data including sexual orientation, sex, and gender identity variables mapped to appropriate MPOG

concepts by the end of December 2025. See P4P Scorecard for point distribution.

Measure #8: Sites will choose a measure where performance is above the ASPIRE threshold for inverse

(outcome) measures (5 or 10%) or a process measure with performance less than threshold (90%) that needs

improvement. Full list of measures available at: https://spec.mpog.org/Measures/Public

Sites must submit their current measure score (November 1, 2023 through October 31, 2024) to the

Coordinating Center by Friday, December 6, 2024, for review and approval. Measure selection form is located

on the MPOG website in the P4P subtab of the Michigan hospitals tab of the quality section. If the

performance threshold is not met, ASPIRE Coordinating Center will assess initial 12-month average score

for November 2023 – October 2024 and compare to 12-month average score for January – December

2025. Absolute percentage point improvement will be evaluated to allocate points. See P4P Scorecard for

point distribution.