If you're like me, you're here because you tried Duckworth-upon-Bilge a few times with disastrous results.... nearly going bankrupt, garbage and ectoplasm everywhere, staff miserable, and reputation abysmal. I found several guides with tips on this level, but the tips were no more than manipulation of the game mechanics to get to three stars, and not in the spirit of the game. For example, keeping an empty wing of the hospital without any radiators so that you can plop a few down when asked then immediately delete them again or continously switching back to another established hospital to do General research and then cashing out.

Several of the guides claimed that this level requires you to forget everything you've learned about the game thus far, but once I dug into it, I found this level taught me more about how to properly manage and build up a hospital than any of the prior levels.

Read on if you want to learn how to master this level without ever going into the red! Many of these tips are not specific to this level but also good guidelines for the game in general.

tl;dr Don't expand your hospital (rooms, wings, or staff) unless you can do so without dropping your balance below 100K. Keep doing Public Targets to build up your cash reserves first. Be patient and you will be rewarded with a stable hospital that's able to manage its costs pretty easily.

In prior levels, I would pause the game immediately upon starting and use about 75% of my cash to build up as much as possible, figuring that meant I would be better prepared for patients and therefore more successful. I didn't realize that high prestige rooms like M.E.G.A scan bring in more patients with more difficult illnesses. At the early stages, you simply won't have the staff or resources to handle those patients, and your cure rate, staff happiness, and reputation will plummet as you fail to keep up.

So how do you know when you're ready to expand? The rule of thumb I followed was to always keep at least $100K cash. If building a new room or hiring more staff would bring you below that threshold, it's going to be very risky and you probably won't have the cash reserves to maintain it.

It will take longer to build up your hospital than in prior levels. Be patient and you will be rewarded with a stable hospital that's able to manage its costs pretty easily. Just keep doing the Public Targets until you have enough money to expand without going below that threshold.

tl;dr Wait until you have at least 5 or 6 requests for a specific treatment room before building it and make sure you can afford it. (See the previous tip)

Just like a real fledging hospital, in the beginning, you don't have the staff or resources to handle high-profile diseases that require custom treatment rooms, like Animal Magnetism or Jest Infection. These are less common but more prestigious illnesses that can benefit you in an established hospital since their treatment is more expensive, but if you don't have the proper staff and resources to handle the extra maintenance and patient load, the result will be a lot of patient deaths and oops now you're bankrupt. Sending a patient home gives a tiny hit to your reputation (-.025), but much less so than trying and failing to cure them.

tl;dr It's totally ok to turn down requests if meeting them is going to jeopardize the stability of your hospital. Once you reject it, you'll get a new one in a few minutes

You may get public targets such as "upgrade a machine" when all your machines are already upgraded to the max or "get a level 5 M.E.G.A Scan room" when you don't even have that room yet. If you don't yet have the resources to manage those tasks, you can reject them. There is a small hit to reputation, but it's much less harmful than attempting to meet the request and getting in over your head.

tl;dr It's better to reject challenges than to attempt them and fail. Be patient and wait until you're ready!

I'm going to start sounding like a broken record here, but it bears repeating. Don't accept a challenge unless there's a pretty reasonable chance that you'll succeed or you'll literally suffer the consequences. And unlike with the previous two, there's no upfront reputation hit from turning down a challenge.

tl;dr Hospital Reputation and Staff Satisfaction are critical for this level. You may be tempted to scrimp by skipping all of these in order to save money, but that's a recipe for disaster!

Aside from being a primary goal for achieving a higher star rating, unhappy staff perform sub-optimally. Happy staff not only means a higher Staff Satisfaction rating but higher cure rates and therefore hospital reputation as well.

In order to maximize both patient and staff happiness, make sure that:

• All rooms have a water fountain, coffee machine, sweets machine, a chair, and a couple of decorative items.
  
• There are enough bathrooms within easy distance. I like to place them in the center of each wing so that they're easily accessible from the whole wing.
  
• The temperature is regulated everywhere.
  
• You've scattered the following everywhere in the hallways:
  
  • Drink machines, snack machines, and sweet machines
    
  • Trash cans
    
  • Benches
    
  • Entertainment items such as magazine racks and bookshelves
    
  • Decorative items. In previous levels, I tended to forget about this in the hallways, but it makes a big difference in happiness levels. I like to use the Display Skeleton and Anatomy Model for decoration both in rooms and hallways. They're a bit more pricey, but they serve the dual purpose of increasing your attractiveness rating and speeding up your training. Yucca plants are good as well, requiring less watering than regular plants with just as big an attractiveness bump, with the added benefit of being able to easily satisfy the "Water 10 Plants" public target

When the level begins, pause the game and do some basic additions to set you up for success! Luckily, unlike other levels, you already have the bare minimum in place: the basic diagnostic and treatments rooms, a couple of doctors and nurses and an assistant. But it's not quite enough.

Rooms
Before starting add only the following rooms:

• Training room
  
• Research room
  
• Resolutions lab

Resolutions lab should be the only advanced treatment room you start out with because curing 5 patients with 8-bitten is a requirement to get to a 1-star hospital.

Staff
You're probably ok not hiring any additional doctors or nurses off the bat, but be sure to hire a second assistant so that they'll be able to take a break without abandoning reception, and of course a janitor. A single janitor should be sufficient in the very beginning.

Probably the biggest question of this level: how do you stay afloat?

tl;dr These are your main (but not only) source of income so it's critical not to shirk on them. Either reject the request immediately so that you can get a new one, or address the request as soon as possible.

There are more details on optimizing your response rates to these in the Public Targets section.

tl;dr If you find yourself in a situation where you think you need a loan, don't. Instead, build up your cash reserves by satisfying more Public Targets.

In other levels, loans can be a useful tool. They enable you to expand quickly, building more rooms and hiring more staff. This means you'll get more patients with more expensive treatments, which equates to more money that you can use to repay the loan eventually. But in this level, you don't get any direct benefit from having more patients. The whole point of this level is that you don't get any money from treatments or retail. The loan payments will simply become an extra drain on your finances, and you won't have created any more avenues for increased income to offset that.

tl;dr Build a research room off the bat, and have one doctor permanently assigned to it with a second optional one, then continuously do "General Research" which results in a $20,000 grant.

The salary of the doctors will easily be recouped by the research itself. If you can train your doctors to have higher Research skills, that will speed up the process, as well as adding items such as the Server or Super Computer.

You'll get occasional staff challenges, outbreaks, epidemics, etc. that will reward you with cash if you succeed, but compared to the other two they're not large. If you can handle them, great, but if not it's not going to harm you overmuch and it's better to be safe than sorry. Watch out because failing some of these challenges can cause a drop in reputation.

Handling Public Targets quickly and efficiently in the key to staying in the black. Other guides have suggested abstaining from doing anything unless it's requested by a Public Target in order to prevent missing out on the reward for a one-time task. That's the opposite attitude you need to have. As a general rule, the Public Targets are objectives that benefit the hospital. If you wait until asked, all of your stats will take a huge hit, and most Public Targets are objectives that are easily repeatable anyway. And as stated in the General Tips section, if it's not an easily repeatable task that you can't handle (such as upgrading a machine when you don't have any eligible for upgrade), you can simply reject that request.

I won't go into detail for all targets, but here are some general tips for some of the major categories.

These are some of the easiest targets to handle quickly, as they are simple jobs such as watering plants, unblocking toilets, and refilling vending machines. When you get one of these targets, you can speed up completion by:

• Updating the job assignments for one of the janitors so they're only allowed to do that single task. Just don't forget to undo this later or other maintenance tasks may start to get seriously behind.
  
• Trigger the "maintenance" overlay and manually click on all the targets that need attention so they don't have to wander around and discover them on their own

If this is a target to upgrade an existing room, you can pretty quickly increase the room level by:

• Increasing its size: don't forget about this one! Not only does increasing the size in and of itself increase room prestige, but it gives you more room to add items.
  
• Adding posters, pictures, etc. to every inch of exposed wall
  
• Putting down a rug (in certain rooms only)
  
• Adding prestige items such as the Trophy Case or award certificates

You may be tempted to undo your changes once the target is complete and get your money back, but don't fall into the trap! Higher prestige rooms increase your hospital reputation and staff and patient happiness.

When you get a target to cure a number of patients with a specific disease or in a specific room, make sure it's one you're already equipped to handle. If you don't have the room or staff required, you can consider acquiring it, but be careful that you're not expanding the hospital too soon.

Similar to the Janitor targets, make sure your best staff is manning the room in question. You can configure your job assignments so that if you have a Ward target, your nurse with Ward Management III is actually there instead of off in cardiology!

tl;dr Make sure your staff are assigned according to their skills, either by manually plopping them into the right rooms or configuring the Job Assignments tab to control which rooms they're allowed to work in.

In the beginning you won't have too many staff with specializations, but as you expand the hospital and train your staff, make sure you're keeping tabs on which rooms your staff are manning. It does you no good to train a doctor in Treatment III and have them working in the GP's office while the doctor with General Practice III is in the Head Office. If you have a broad enough scope of staff, you can set their Job Assignments to ensure they're working to their strengths, but if not, you can always manually pick up a doctor or nurse and plop them down in the room you want them to work.

tl;dr Don't just look at staff skills when you hire them, also check their personality traits to see how they will impact the hospital

It's easy when hiring staff to just look at the skills they're trained in. This is important, of course, but they also have personality traits that affect how they work. Some are grumpy (-10% happiness), others are motivated (+20% speed), etc. Most staff have at least one negative trait. I'd advise avoiding the Grumpy trait for this scenario since staff satisfaction is one of the primary things you're graded on.

tl;dr Build a training room with 3-4 desks and constantly train your staff, even if you haven't received a request to do so.

One of the best things you can do to promote the smooth running of your hospital is to have well-trained staff. If they have a negative personality trait, you can generally train them to offset that, for example training in Emotional Intelligence for Grumpy Employees and Motivation for Unmotivated employees. Well trained and high-level staff contribute heavily to cure rates and hospital reputation.

This section outlines the factors that can negatively affect staff happiness and what to do about it!
On the Info tab, you can see how a staff's happiness, traits, and feelings affect their productivity.
Check the Mood tab of the staff profile to see details on what's affecting their happiness and act accordingly.



Having a open training slot is a -5% hit on your staff's happiness. Keeping them trained doesn't just improve the state of the hospital! Emotional Intelligence adds an automatic +10% happiness boost as well, so that's always a good option for this level.


This one seems pretty obvious, do I really need to tell you that your staff want to be paid well? Make sure you've at least met the "satisfied" level if not a little higher. You can quickly address any staff complaints by hitting the "Satisfy Pay Requests" button on the Pay Review tab.


For some reason staff will not automatically address their most basic needs. They will only use the bathroom or fully satisfy their hunger/thirst if they're actually on a break. Having a water fountain, coffee machine, and chair in their room will help, but not alleviate the need for an actual break.

If you have staff complaining about this, double check that you have a staff room and bathrooms relatively close to where they're working. If you only have a staff room in one wing, it might take the entire duration of their break just to get there, and they won't have time to address their needs. If they're still complaining, you can always force them to take a break by picking them up and dropping them in the staff room.

Make sure the staff room is near the bathrooms and put vending machines in the staff room as well.


Well-decorated and high-level rooms can actually have a much bigger impact on staff happiness than you might think. An "Outstanding Room" bonus gives you a whopping +30% happiness boost! Getting a level 5 staff room will impress every member of your staff when they visit.

This is a super tricky level, make no mistake. But I hope my tips will help you reach the stars! (Literally. 3 of them to be exact). Comment and tell me if you've stumbled across any other tips for this level.