As is typical with sandbox games, nothing is unmissable and you can get almost everything just by 3-starring every level.
Do note that stars are cumulative; i.e. in any/every hospital you work to get 1-star, then the 2nd star then the 3rd. Stars can't be removed. You can return to any hospital at any point to work on the remaining stars.
Research progress (and rooms available!) are persistent across all hospitals. Hence it may be helpful (albeit unlikely) to return to an older hospital with new gear/upgrades available and be more easily able to get it to 3 stars.
On that point specifically; research being global is useful - switch back to an established hospital where you have strong research anytime you come across new conditions that need a new room researching. you don't have to build a research facility in every new hospital!
{{High Brow}} and {{I'd Like To Thank My Mother}} may well be the only real challenges here in the base game...
...however with the DLC added as well this turns into 100+ hours to 100% this game, just to get all the stars if nothing else (see {{The New Gold Standard}} and the second/third variations of it...).
Single-player only
Difficulty does NOT affect achievements
1 missable achievements (plus 6 unknown)
Sign in with Steam or Xbox to track your progress, and:
Cure 1 Patient
It'll be impossible not to get this in your first hospital...
Have a Level 10 Hospital
This will be impossible to avoid during the campaign.
Cure 1000 Patients
Conduct 25 Machine Upgrades
You'll get this without even trying...
Shoot 1 Monobeast
Shoot one monobeast! These are small creatures that run around your hospital - mostly in dirtier hospitals. Sometimes they run loose on the floor, other times you may need to move furniture (e.g. drinks/snack machines) to disturb them. Click on them to shoot them!
Note they move quite quick, but you have to be on at least Normal time speed for them to be shootable. On Slow time, the cursor won't change to a crosshair and they won't be shootable.
They look like a sticking plaster or a boring sausage. Quite weird really...
Capture 100 Ghosts
You'll get this without even trying...
Complete a Multiplayer Challenge
You can do this right from the beginning - select any challenge using the icon right in the top-right corner and let it play out. you don't have to win - or indeed get any points/progress at all - it just has to reach conclusion.
Earn 15 Gold Stars
Base game
You'll get this naturally as you progress through the scenarios.
Injure someone with an exploding machine
"Injure someone with an exploding machine" - you'll end up with this accidentally through the campaign at some point. Its not worth trying for.
Have a Level 20 Hospital
Your hospital gains level by you building more stuff in it; rooms, items, anything. Just keep building. Ofc this will be easier later in the campaign, and you can revisit and resume any hospital at any time to help grind this out if you wish.
Earn 10,000 Kudosh
Earn 30 Gold Stars
Base game
See {{County-Wide}} - you'll get this naturally.
Complete 50 Research Projects
Some projects remain locked until late in the campaign.
Remember that research opportunities and progress are shared across all hospitals - so when you get somewhere new and have an objective on something you haven't researched yet just flip back to a previous hospital to capitalise on the established research resource you will have already built up there to get it done faster.
Win every award in a single hospital
The hardest award will be 'no deaths'. And despite what the description says, you have to get all awards in the same year.
This will likely be easiest by revisiting the first/early hospitals after you have progressed further into the campaign to unlock better machines/rooms/etc.
Don't forget you can quickload to cheat out of random deaths....
Flagged as partially glitched as the achievement description is less specific than the actual requirement!
Train a World-Class Psychiatrist
Same as {{Dr Know}} and {{Cut Above}} but for Psychiatry.
This means all 5 skill slots all on psychiatry.
Make sure to hire someone either with no skills or just with psychiatry; then keep working and training them as soon as they come up for training.
You'll likely have to grind this out in a level a ways after getting 3 stars in it.
Train a World-Class Researcher
Same as {{Jung at Heart}} and {{Cut Above}} but for Research.
This means all 5 skill slots all on research.
Make sure to hire someone either with no skills or just with research; then keep working and training them as soon as they come up for training.
You'll likely have to grind this out in a level a ways after getting 3 stars in it.
Complete Superbug Project "Hair Removal"
Superbug initiative
Reach $50,000,000 Organisation Value
You'll probably get this naturally as part of going for 3 stars on all levels in the base game.
The profitability of each hospital matters here; i.e. get revenue up and keep costs down.
You can return to older hospitals to further improve them - especially as you'll subsequently have gained access to more advanced rooms/upgrades/etc.
Run 50 Marketing Campaigns
Marketing rooms get unlocked a few hospitals into the campaign. Make sure to run a few campaigns in each hospital to help grind this out during your normal run through.
Knock the socks off of Bartholomew F. Yeti
Bigfoot DLC
Knock the socks off of Bartholomew F. Yeti. Bartholomew F. Yeti is one of VIPs - he will visit sometime at Selbard hospital. Make sure he leaves happy...
Earn 1 Star at each hospital in the Pointy Mountains
Base game
Complete the "Cheesier Gubbins" Research Project in Swelbard
Bigfoot DLC
Finish the "Cheesier Gubbins" research in Swelbard.
Train a World-Class Surgeon
Same as {{Dr Know}} and {{Jung at Heart}} but for Surgery.
This means all 5 skill slots all on surgery.
Make sure to hire someone either with no skills or just with surgery; then keep working and training them as soon as they come up for training.
You'll likely have to grind this out in a level a ways after getting 3 stars in it.
Surgery becomes available 4 or so hospitals into the campaign.
Earn 45 Gold Stars
Base game
See {{County-Wide}} - you'll get this naturally.
Cure a patient with Frogborne
Close Encounters DLC
Your first Frogborne patients will appear in Camouflage Falls - research Toad Hall first though.
Earn 1 Star at each hospital on Pebberley Island
Pebberley Island DLC
Get a Curing Spree on Topless Mountain
Pebberley Island DLC
Cure a wave of 10 patients at a time without failing any, and continue to do so to build the streak. You should be able to get this on wave 10+ after training the staff and upgrading the machines.
Earn 1 Star at each hospital in Close Encounters
Close Encounters DLC
Earn 54 Gold Stars
Bigfoot DLC
You'll need all the stars in the base game and some of the DLC ones - this will take a long time (80+ hours).
Expose 50 Alien Infiltrators
Close Encounters DLC
These appear in Goldpan and Chasm 24. They are aliens disguised as patients. They make electrical sounds, which you can use to spot them. Spot them and send them home... ...50 times.
Receive the highest possible Eco Rating
Off the grid DLC
Cure a patient in the Herb Garden
Off the grid DLC
This is a treatment room that gets unlocked in the Old Newpoint level in the Off The Grid DLC. It needs a nurse to operate it.
Have a Level 5 De-lux Clinic at the Underlook Hotel
Bigfoot DLC
Have a Level 5 De-lux Clinic at the Underlook Hotel - do this in the usual way by upgrading the machine and putting pictures all over the walls.
Complete Superbug Project "Learning Machine Learning"
Superbug initiative
Complete R.E.M.I. X versions of Hogsport, Lower Bullocks & Flottering
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Earn 63 Gold Stars
Pebberley Island DLC
Now 100+ hours of play. Also see {{The New Gold Standard}}
Shoot 10 Monobeasts in a row without missing
Like {{Low Brow}} - but get 10 in a row without missing one. The easiest way to do this is to find some monobeasts, pause the game, then rapidly unpause (space), click to shoot, then pause again - then set up for the next one. Rinse & repeat and it should be easy to get 10 and pop this achievement.
Complete 50 Research Nodes
Superbug initiative
Activate every Robo-Janitor prototype in Chasm 24
Close Encounters DLC
You get access to robo janitors in Chasm 24. You can have up to 5 in a single hospital. You get them for free by buying plots, but you don't get to choose which type you'll receive on any given plot. If you complete Chasm 24 with 3 stars then you gain the ability to buy robo janitors and can then choose whatever you want.
This achievement may not unlock without quitting/reloading the game after having completed the objectives.
Sign in to track your progress against these checklist items
Earn 1 Star at each hospital in Off The Grid
Off the grid DLC
Earn 72 Gold Stars
Close Encounters DLC
Yeah you'll be playing for a long while.... Also see {{The New Gold Standard}}
Unlock every plot in Overgrowth
Pebberley Island DLC
In this map you gain plots not by buying them but instead by completing objectives. There are 32 total to unlock - and there'll be a lot of patients to get to that point; you'll need at least 10 GP offices, 6 receptions and at least 2 of all the other diagnosis rooms.
Complete Wave 42 on Topless Mountain
Pebberley Island DLC
Earn 81 Gold Stars
Off the grid DLC
Yup, you're going to be at this a looooonnngggg time...
Complete R.E.M.I. X versions of Mitton University, Tumble & Flemington
Maximise your Green Energy capacity in Windsock
Off the grid DLC