Towards a Conceptual Modelling Framework for Participative Hybrid Simulation in Healthcare

Hybrid simulation is increasingly recognised as a powerful tool for addressing complex decision-making challenges in healthcare. This approach enables researchers and decision-makers to investigate the interactions among various components of healthcare systems, assess interventions and policy alternatives, and evaluate their potential effects without interfering with actual operations. By integrating diverse simulation techniques, including Discrete Event Simulation (DES), System Dynamics (SD), and Agent-Based Simulation (ABS), hybrid simulation effectively captures both the operational and behavioural dimensions of healthcare systems. This comprehensive integration enhances understanding of system performance and facilitates evidence-based decision-making to improve efficiency, accessibility, and care quality.

However, despite its benefits, hybrid simulation remains underused in research focused on the implications of demographic changes, particularly population ageing, on healthcare service availability and organisation. Population ageing is one of the most significant global transformations of the late twentieth and twenty-first centuries, driven by long-term declines in fertility and mortality. In low- and middle-income countries (LMICs) such as Brazil, this shift is occurring rapidly and unevenly, placing additional pressure on already constrained social and health systems. Brazil's ageing process unfolds in a context of persistent social inequalities and regional disparities, further increasing demand for health services and challenging their capacity to meet the complex needs of older adults. Consequently, policymakers and healthcare planners increasingly recognise the need for analytical tools that can support service evaluation, guide future capacity planning, and promote sustainable models of care for an ageing population.

Simulation offers an opportunity to explore such challenges by enabling experimentation with computer models that represent real-world healthcare processes and interactions. These models can be used to test alternative strategies for resource allocation, service organisation, and policy interventions before their actual implementation. However, despite its promise, the hybrid simulation literature has not fully explored how these models can be co-developed with stakeholders, such as clinicians, managers, and policymakers, who hold valuable experiential knowledge of the systems being modelled. The lack of active stakeholder participation, particularly during the conceptual modelling (CM) stage, is a recognised limitation in the field. Conceptual modelling defines what the simulation will represent, the level of detail it will include, and the assumptions that will underpin it. Without stakeholder involvement in this process, models risk being misaligned with real decision-making contexts and may fail to produce practical conclusions.

This thesis addresses this gap by proposing a Participative Hybrid Simulation Conceptual Modelling Framework, which adapts and extends the PartiSim methodology, a multi-methodology framework developed initially for participative discrete-event simulation in healthcare. PartiSim provides a structured approach for engaging stakeholders through facilitated workshops that guide problem definition, conceptual model development, and validation. Building on its principles, this research incorporates the participative features of PartiSim into hybrid simulation, thereby creating an integrated process that supports stakeholder collaboration in designing hybrid models.

The proposed framework was developed and evaluated through a real-world case study conducted in Santo Amaro and Cidade Ademar (SACA), two boroughs of São Paulo, Brazil. The case study focused on understanding the impact of population ageing on the local healthcare network, particularly the interaction between primary and secondary care services for older adults. Stakeholders from diverse backgrounds, including healthcare managers, clinicians, operational staff, and public health representatives, took part in facilitated workshops. These sessions encouraged collaborative problem structuring, identification of system boundaries, and the co-development of a conceptual hybrid model integrating both process and behavioural perspectives.

By engaging participants throughout the modelling process, the study captured a richer and more nuanced understanding of the challenges faced by the SACA healthcare system. The participative approach allowed stakeholders to express their views, share experiential knowledge, and develop a shared vision of the system under study. This process enhanced communication between technical modellers and practitioners, increased transparency in modelling decisions, and improved confidence in the resulting model. Moreover, it encouraged learning among participants, strengthening their capacity to use simulation for decision support.

The framework developed through this research provides practical guidance for modellers seeking to apply hybrid simulation in participative contexts. It sets out stages, activities, and tools for involving stakeholders in conceptual modelling, and offers insights into adapting facilitated approaches to hybrid simulation. The research reflects on methodological and practical adjustments made during the Brazilian case study, including tailoring tools to hybrid model requirements and modifying facilitation techniques to ensure inclusive participation. The final framework incorporates these lessons, offering a structured, replicable approach to developing participative hybrid simulation studies.

In summary, this thesis contributes to both theoretical and practical advances in hybrid simulation in healthcare. It demonstrates that participative methods, when integrated into hybrid simulation, can strengthen the relevance, credibility, and usability of models. The study provides one of the first comprehensive attempts to embed stakeholder engagement within the conceptual modelling of hybrid simulation, particularly in the context of a developing country. It also highlights how such an approach can support better-informed decisions in complex healthcare systems affected by demographic and organisational change. The proposed framework offers a foundation for future research and practice, enabling hybrid simulation to become a more inclusive and impactful tool for healthcare planning and policy analysis in settings characterised by limited resources and growing population needs.