Improvement of dialysis access management depends on technical skill but also on effective choice, construction, monitoring and revision of the access. Surgical procedure is only one step of a complex course, beginning with the referral of patients to nephrologists. Using two process quality indicators, we describe the evolution of access management at our centre, where access surgery and access-related activities are performed by nephrologist. The first process indicator is based on the prevalence of temporary access at first dialysis (TA1st) in end stage renal disease ESRD patients, the second one measures the prevalence of permanent central venous catheters (%CVC) in dialysis population. TA1st increased to 27.1% in 1999, more than twofold compared to the previous year. There was also an increase in %CVC from 20.6 to 26.3%. Native access remained the most utilised, well above 70% of dialysis patients. Our process monitoring suggests a rapid worsening of late referral, as indicated by the increasing use of temporary catheters at the beginning of chronic dialysis. Increasing surgical activity and diagnostic procedures were only partly effective in containing the rise in CVC. Venous sparing, early referral, Continuous Quality Improvement and a multiprofessional access-team co-ordinated by a nephrologist could be the key-elements in facing the never-ending-story of dialysis vascular access.