Abstract
Background. Given the water scarcity crisis and high water consumption in hospitals, it is crucial to identify and prioritize water recycling strategies in these facilities. This study aimed to identify the most appropriate water recycling strategies and prioritize them based on multiple criteria.
Methods. This descriptive–analytical study was conducted in the Spring of 2025, involving eight selected public hospitals with high water consumption in Markazi Province. Initially, through literature review, field visits, and semi-structured interviews with 17 experts in hospital water and wastewater management, potential recycling strategies and relevant evaluation criteria were identified. Qualitative data were analyzed using content analysis in MAXQDA 2022. In the quantitative phase, the criteria were weighted using the Shannon entropy method, and the alternatives were prioritized using the TOPSIS multi-criteria decision-making model. All calculations were performed using Microsoft Excel.
Results. Findings showed that recycling dialysis wastewater (score: 0.87), rainwater harvesting (score: 0.78), and recycling medical equipment wash water (score: 0.75) were the top three prioritized options. The economic criterion, with a weight of 0.35, was identified as the most influential factor in the decision-making process.
Conclusion. The results indicated that the prioritization of water recycling strategies in hospitals is influenced by a combination of economic, technical, environmental, and operational criteria. The TOPSIS model identified dialysis wastewater recycling as the most favorable option. Therefore, it is recommended to implement a pilot project for recycling dialysis wastewater, develop localized guidelines for hospital water recycling systems, and provide specialized training for hospital personnel.
Extended Abstract
Background
Water plays a vital role in hospitals, as it is essential for drinking, sterilization, infection control, dialysis, and maintaining environmental hygiene. In water-scarce countries like Iran, hospitals face challenges in maintaining an uninterrupted water supply, especially during crises. With climate change, rising temperatures, and urbanization, water scarcity is projected to affect over half the global population by 2050. In Iran’s semi-arid regions, such as Markazi Province, declining rainfall and groundwater levels underscore the need for sustainable water management in hospitals.
Water recycling is an essential strategy because of its economic advantages and compatibility with hospital infrastructure. However, choosing the best recycling technology involves complex, multi-faceted decision criteria. Multi-Criteria Decision Making (MCDM) methods like TOPSIS have proven effective for evaluating wastewater treatment options. Although they have been successful in related areas, TOPSIS has rarely been used for hospital water recycling in Iran. This study aims to develop a TOPSIS-based MCDM model to prioritize water recycling strategies in public hospitals of Markazi Province.
Methods
This applied, descriptive–analytical study was conducted during the Spring of 2025 across eight public hospitals in Markazi Province, which, based on data from the Markazi Province Water and Wastewater Company, had the highest water consumption and wastewater production. A mixed-methods approach was used. The qualitative phase involved field inspections, document reviews, and semi-structured interviews with 17 experts in hospital water and wastewater management. Through content analysis using MAXQDA 2022, six potential water recycling strategies were identified along with key evaluation criteria across four dimensions: technical, economic, environmental, and operational.
In the quantitative phase, the decision matrix was constructed based on expert scoring of each alternative against the identified criteria, using a five-point Likert scale. Criteria weights were calculated using the Shannon Entropy method to ensure objectivity. Subsequently, the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) was applied to rank the alternatives based on their proximity to an ideal solution. All numerical calculations were carried out using Microsoft Excel.
The identified alternatives were:
1. Dialysis wastewater recycling
2. Rainwater harvesting
3. Recycling wash water from non-contaminated medical equipment
4. Greywater recycling from non-infectious hospital areas
5. Cooling tower water reuse
6. Recycling wash water from non-contaminated dishwashing units
Ten sub-criteria were also defined, such as ease of implementation, system reliability, operation and maintenance (O&M) costs, and staff acceptance. The evaluation framework accounted for both tangible and intangible dimensions of hospital operations.
Results
The results revealed that the dialysis wastewater recycling strategy had the highest priority with a TOPSIS score of 0.87. This was followed by rainwater harvesting (0.78) and recycling of medical equipment wash water (0.75). These three options demonstrated a favorable balance of economic feasibility, technical viability, and manageable health risks. The lowest-ranked option was recycling dishwashing water (0.58), primarily due to elevated contamination risk and higher treatment complexity.
The economic criterion proved to be the most influential factor with a total weight of 0.35, reflecting hospital administrators’ primary concerns about capital and operational expenditures. Technical considerations (weight = 0.30) followed, emphasizing the importance of ease of implementation and maintenance. Environmental impacts (0.20) and operational aspects (0.15), although less dominant, still played meaningful roles in the final prioritization.
The ranking aligned with global best practices. For instance, dialysis water reuse was endorsed by Tarrass et al. (2024) as a circular economy solution in nephrology, while rainwater harvesting has proven effective in German and American hospitals in reducing potable water use. Similarly, greywater reuse and cooling tower water recovery have been found to yield measurable savings but require robust infrastructure and risk management strategies.
The diversity in the expert panel-comprising engineers, hospital managers, university faculty, and public utility professionals-strengthened the reliability of the data. With a mean work experience of 14.8 years, the panel provided deep insights into practical and contextual factors influencing hospital water systems.
Conclusion
This study demonstrated that using a structured multi-criteria decision-making model, such as TOPSIS, enables the effective evaluation of complex water recycling options in hospital environments. Dialysis wastewater reuse was identified as the most favorable strategy due to its high volume, consistent quality, and cost-effectiveness. It is recommended to initiate a pilot implementation of this option, followed by the development of localized operational guidelines and technical training programs for hospital staff. Policymakers should also consider introducing financial incentives to encourage hospitals to invest in sustainable water practices. Ultimately, integrating qualitative expert input with quantitative MCDM tools offers a replicable and adaptable approach for water resource optimization in healthcare infrastructure.
Practical Implications of the Study
1. Implementing dialysis wastewater recycling can significantly reduce hospital water consumption without disrupting clinical operations.
2. Economic feasibility is the key driver for hospital administrators, guiding investment decisions in water recycling technologies. 3. Creating localized operational guidelines and training programs will improve the safe and efficient implementation of recycling systems.
4. The TOPSIS-based prioritization model offers a replicable framework for sustainable water management in healthcare facilities across Iran.