University of Tehran Press Journal of Fine Arts: Architecture & Urban Planning 2228-6020 30 4 2025 12 22 A Decision-Making Framework for Selecting Sustainable Hospital Projects in Iran A Decision-Making Framework for Selecting Sustainable Hospital Projects in Iran 71 82 105950 10.22059/jfaup.2026.408707.673153 FA Samira Mahmoudkelayeh PhD Student of Construction and Project Management, Department of Construction and Project Management, School of Architecture, College of Fine Arts, University of Tehran, Tehran, Iran. 0009-0004-6354-1733 Seyed Hossein Hosseini Nourzad Assistant Professor, Department of Construction and Project Management, School of Architecture, University of Tehran,Tehran, Iran. 0000-0002-5908-7986 Abbas Ostadtaghizadeh Abbas Ostadtaghizadeh Associate Professor, Department of Health in Emergency and Disaster, School of Public Health, Climate Change and Health Research Center (CCHRC), Tehran University of Medical Sciences, Tehran, Iran. 0000-0001-5260-6221 Journal Article 2025 09 24 Hospitals are indispensable pillars of health systems and constitute critical social infrastructure. Beyond their primary mission of delivering medical care, they play broader societal roles by promoting equitable access to health services and enhancing community well‑being. However, hospitals also impose considerable environmental burdens through intensive energy and water consumption, substantial waste generation, and significant greenhouse gas emissions. These realities highlight the urgent need to embed sustainability principles into hospital planning, design, and project portfolio selection. In Iran, this challenge is particularly pressing. The country’s average hospital bed availability stands at only 1.92 per 1,000 people, far below the global average of 3.28. This disparity underscores the necessity of expanding hospital capacity, yet such expansion must be pursued in ways that are both socially equitable and environmentally responsible. Despite this urgency, Iran currently lacks a structured framework for sustainability‑oriented hospital project portfolio selection. Previous studies have largely emphasized environmental considerations or focused on single‑building evaluations, while social dimensions and portfolio‑level decision‑making remain underexplored. This study addresses this gap by proposing a comprehensive framework for prioritizing sustainable hospital projects tailored to the Iranian context. The research unfolded in four stages. First, a systematic literature review identified sustainability criteria and indicators from international scholarship. Second, the Delphi method was employed to refine these criteria and achieve expert consensus, ensuring their relevance to Iran’s healthcare infrastructure and policy conditions. Third, the Best–Worst Method (BWM) was applied to determine the weights of the criteria, offering a robust mechanism for capturing expert preferences. Finally, the MARCOS method was used to prioritize a real hospital project portfolio, consisting of nine level‑3 hospitals in Iran, which represent county‑scale facilities of national importance. The findings revealed that social dimensions outweigh environmental ones, with Health and Safety, Well‑being, and Energy emerging as the most critical sustainability groups. The framework also exposed areas where current hospital designs align with sustainability priorities and where notable gaps persist. For instance, while some indicators were consistently met due to regulatory requirements, others—such as daylight utilization and Clean and renewable energy production—were frequently neglected despite their recognized importance. Overall, the results demonstrated that only a subset of sustainability indicators is fully achieved across the portfolio, while many remain insufficiently addressed, underscoring the need for deeper integration of sustainability principles. This research contributes to the literature by consolidating measurable social and environmental indicators suitable for project portfolio decision‑making, integrating BWM for robust weighting and MARCOS for comprehensive ranking, and demonstrating the framework’s applicability through a real case study. Although economic indicators were excluded due to measurement challenges, the framework nonetheless provides a structured approach to evaluating hospital projects in terms of sustainability. In conclusion, the proposed framework offers both theoretical and practical value. It equips policymakers and health system managers with a transparent tool to prioritize hospital investments, ensuring that future projects are not only clinically effective but also socially equitable and environmentally responsible. Future research is encouraged to extend the framework by incorporating resilience alongside sustainability, thereby enabling more holistic evaluation and long‑term strategic alignment in healthcare infrastructure planning.  Hospitals are indispensable pillars of health systems and constitute critical social infrastructure. Beyond their primary mission of delivering medical care, they play broader societal roles by promoting equitable access to health services and enhancing community well‑being. However, hospitals also impose considerable environmental burdens through intensive energy and water consumption, substantial waste generation, and significant greenhouse gas emissions. These realities highlight the urgent need to embed sustainability principles into hospital planning, design, and project portfolio selection. In Iran, this challenge is particularly pressing. The country’s average hospital bed availability stands at only 1.92 per 1,000 people, far below the global average of 3.28. This disparity underscores the necessity of expanding hospital capacity, yet such expansion must be pursued in ways that are both socially equitable and environmentally responsible. Despite this urgency, Iran currently lacks a structured framework for sustainability‑oriented hospital project portfolio selection. Previous studies have largely emphasized environmental considerations or focused on single‑building evaluations, while social dimensions and portfolio‑level decision‑making remain underexplored. This study addresses this gap by proposing a comprehensive framework for prioritizing sustainable hospital projects tailored to the Iranian context. The research unfolded in four stages. First, a systematic literature review identified sustainability criteria and indicators from international scholarship. Second, the Delphi method was employed to refine these criteria and achieve expert consensus, ensuring their relevance to Iran’s healthcare infrastructure and policy conditions. Third, the Best–Worst Method (BWM) was applied to determine the weights of the criteria, offering a robust mechanism for capturing expert preferences. Finally, the MARCOS method was used to prioritize a real hospital project portfolio, consisting of nine level‑3 hospitals in Iran, which represent county‑scale facilities of national importance. The findings revealed that social dimensions outweigh environmental ones, with Health and Safety, Well‑being, and Energy emerging as the most critical sustainability groups. The framework also exposed areas where current hospital designs align with sustainability priorities and where notable gaps persist. For instance, while some indicators were consistently met due to regulatory requirements, others—such as daylight utilization and Clean and renewable energy production—were frequently neglected despite their recognized importance. Overall, the results demonstrated that only a subset of sustainability indicators is fully achieved across the portfolio, while many remain insufficiently addressed, underscoring the need for deeper integration of sustainability principles. This research contributes to the literature by consolidating measurable social and environmental indicators suitable for project portfolio decision‑making, integrating BWM for robust weighting and MARCOS for comprehensive ranking, and demonstrating the framework’s applicability through a real case study. Although economic indicators were excluded due to measurement challenges, the framework nonetheless provides a structured approach to evaluating hospital projects in terms of sustainability. In conclusion, the proposed framework offers both theoretical and practical value. It equips policymakers and health system managers with a transparent tool to prioritize hospital investments, ensuring that future projects are not only clinically effective but also socially equitable and environmentally responsible. Future research is encouraged to extend the framework by incorporating resilience alongside sustainability, thereby enabling more holistic evaluation and long‑term strategic alignment in healthcare infrastructure planning.  https://jfaup.ut.ac.ir/article_105950_1e3e72ead2fe65c70ebeb0b5905654fb.pdf