Strategic alignment of emergency department key performance indicators with Saudi Vision 2030 healthcare transformation cornerstones: an expert-rated policy mapping study

<title>Abstract</title> <p>Background Emergency departments are central to access, quality, patient flow, resource use, and workforce performance. Saudi Vision 2030 and the Health Sector Transformation Program require healthcare performance systems to support Better Health, Better Care, Better Sustainability, and Better Workforce. This study examined whether commonly used emergency department key performance indicators reflect these four strategic cornerstones. Methods A quantitative policy-mapping study was conducted. A total of 176 candidate emergency department indicators were identified from Saudi national frameworks, Saudi institutional research, and international evidence. After de-duplication and eligibility screening, 86 unique indicators were retained. Two independent experts rated every indicator against each cornerstone using a three-level ordinal scale: 0, no alignment; 1, indirect alignment; and 2, direct alignment. A third expert adjudicated discordant ratings. Weighted Cohen’s kappa assessed pre-adjudication agreement. Frequencies, percentages, mean alignment scores, a chi-square test, and ordinal logistic regression were calculated using IBM SPSS Statistics version 28.0. Results Inter-rater reliability ranged from fair to substantial across the four cornerstones (weighted kappa 0.41–0.72). Better Care had the highest direct alignment, with 79 of 86 indicators (91.9%), followed by Better Sustainability with 48 (55.8%), Better Workforce with 37 (43.0%), and Better Health with 16 (18.6%). Mean alignment scores were 1.92, 1.47, 1.27, and 0.86, respectively. Alignment distribution differed significantly across cornerstones (chi-square = 142.3, p &lt; 0.001). Relative to Better Care, indicators were less likely to achieve higher alignment with Better Health (OR = 0.08, p &lt; .001) and Better Workforce (OR = 0.33, p = .004). Conclusions The evaluated emergency department indicator portfolio was strongly concentrated on immediate care delivery and operational throughput. Population health, workforce, and sustainability dimensions were comparatively underrepresented. A more balanced emergency department performance framework could connect frontline operations more directly to national health-system strategy while preserving essential clinical flow and safety measures.</p>