In recent years, the market has shown increasing interest in pump-turbines. The prompt availability of pumped storage plants and the benefits to the power system achieved by peak lopping, providing reserve capacity, and rapid response in frequency control are providing a growing advantage. In this context, there is a need to develop pumpturbines that can reliably withstand dynamic operation modes, fast changes of discharge rate by adjusting the variable diffuser vanes, as well as fast changes from pumping to turbine operation. In the first part of the present study, various flow patterns linked to operation of a pump-turbine system are discussed. In this context, pump and turbine modes are presented separately and different load cases are shown in each operating mode. In order to create modern, competitive pump-turbine designs, this study further explains what design challenges should be considered in defining the geometry of a pump-turbine impeller. The second part of the paper describes an innovative, staggered approach to impeller development, applied to a low head pump-turbine project. The first level of the process consists of optimization strategies based on evolutionary algorithms together with 3D in-viscid flow analysis. In the next stage, the hydraulic behavior of both pump mode and turbine mode is evaluated by solving the full 3D Navier-Stokes equations in combination with a robust turbulence model. Finally, the progress in hydraulic design is demonstrated by model test results that show a significant improvement in hydraulic performance compared to an existing reference design.