The Obstetric Clinic at the Johns Hopkins Hospital was evaluated on four occasions during the past 8 years. In 1980, there were major inefficiencies because of a block patient appointment system and late physician arrival. Clinic goals were largely undefined. The institution of a staggered appointment system, the naming of an on-site physician director who encouraged physicians to arrive on time, and the delegation of specific responsibilities to the nurses and clerks resulted in improved patient transit time. In 1981, 72% of patients had left by 2 hours after their arrival, compared with only 4% in 1980. The departure of the physician director was associated with considerable backsliding in patient transit time because of late physician arrival. There was a corresponding decrease in appointment-keeping from 90 to 78%. Patients were satisfied with their care but very dissatisfied with the waiting time. The return of the physician director and the reaffirmation of the roles of nurses and clerks reversed much of the backsliding. Our study suggests that improvements in teaching-hospital obstetric clinics are difficult to sustain without strong leadership. We believe that further improvement will require a major reorganization of ambulatory care for women. The feasibility of establishing a comprehensive program based on a group practice model is currently being studied.