**1. Introduction**

Extra-corporeal membrane oxygenation (ECMO) or extra-corporeal life support (ECLS) is quickly becoming a well-established form of therapy for patients presenting in severe respiratory failure and/or cardiogenic shock. The fundamentals of therapy, while technically challenging and involving a complex dynamic humanartificial circuit system, also requires a huge reliance on a multi-disciplinary team and an institutional infrastructure with robust administrative support at all levels to function effectively. While the medical and technical aspects of therapy are covered extensively in this text—and the others in this series [1, 2], a common fundamental question that is often asked is "how do we start and develop a program?" The development of an ECMO/ECLS program is far more complex than organizing a small group of interested providers and acquiring the hardware necessary for support—as such, the goal of this chapter is to outline those steps necessary to help establish a foundation for a successful institutional program.
