Flexibility and real options analysis in emergency medical services systems using decision rules and multi-stage stochastic programming

•Novel approach to EMS infrastructure systems design, planning, and operations under uncertainty.•Models strategic flexibility as Real Options (RO) using multi-stage stochastic programming and decision rules.•Differs from standard RO analysis by emulating real-world decision-making.•Objective function minimizes expected total costs; outputs are optimal initial configuration and decision rules.•Flexible solution provides lower expected cost than stochastically optimal rigid solutions, especially valuable when required incident coverage rate is >95%.