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We examined data from the Canadian Organ Replacement Registry, and from a special substudy of CORR, to determine whether changes have occurred in practice patterns before and after the 1999 Canadian Society of Nephrology guidelines were published. Second, we used data from the Dialysis Outcomes and Practice Patterns Study to calculate the impact of observed deviations from guideline targets and estimated potential gains in life years that might accrue if guideline targets were achieved in all Canadian hemodialysis patients. For dialysis dose and hemoglobin targets, there was a significant improvement in Canadian facility performance over time. On the other hand, vascular access care showed a worse pattern with increased catheter use. A calculation of attributable risk, which assumes causality, suggests that 49 percent of deaths could be averted if all patients currently outside the guidelines achieved them over the next five years. When expressed as an annual death rate per hundred patient years, this corresponds to a decrease from 18 to 10.1 deaths per 100 patient years. We conclude that promoting a facility-based culture of quality improvement based on achievement of guideline targets is supported by international and Canadian observational data from the DOPPS. In the future, the impact of such an approach should be assessed empirically by correlating changes in practice over time with changes in outcomes.