Dialysis for ESRF is very expensive, complex and covers multiple disciplines. Medicine, esp. surgery, is resistant to change, patient safety being a major concern. Hence, changing Dialysis Management is difficult, slow and beset by opposition. Over the last 20 years, we have changed the Dialysis Managemet at our institution profoundly: * Abandonment of Fistula Grafts * Management of most Fistula problems with Endovascular Technics as OPLA Procedures * US the principle diagnostic tool * US at all levels of Dialysis Care by all team members * Expansion of home HD to ~50% of our Dialysis population * Improvement of Dialysis Systems * Minimisation of Vascath use, elimination of L sided Vascaths * Development of Seldinger PD Access & Urgent Start PD. * Development of “one-stop shop” Dialysis Access Clinics. How to drive change: 1. Change can be driven “top down” or “bottom up”(“Jesuit Planning”) 2. A careful, step-wise approach, introducing new technics, technologies & practices from single patients to Established Unit Practice. 3. Test out a new technology/idea/application in a clinical setting with support from clinical stakeholders & the patient on a small number of cases! 4. If successful, Team Meeting with all stakeholders in the Dialysis Team to: a. Discuss pros & cons & practicalities of the innovation b. Set up a small, well defined Pilot Project with emphasis on safety! 5. If successful, the innovation can be introduced on a limited scale with: a. Emphasis on clinical effectiveness, cost effectiveness & safety b. Real time clinical audit c. Frequent review & discussion with Team 6. If successful, the innovation should then be discussed with management, properly staffed & funded & be driven to new default unit policy.