More Information

For More Information

For more information on the CCP programme, please contact:

MOPS Points

The participants in the Collaborative Clinical Pathways project can claim one MOPS credit per hour under CME/ Practice improvement activity.  The Practice improvement form can be completed by each GP to keep and use for documentary purposes in case of a college audit of MOPS documentation.

A Practice Improvement Form for Activities that will Improve Your Practice - 2012.02.01#2

Key Pathway Educators

Below is a list of key people to contact if you would like to receive training on a particular pathway or if you have any additional questions.

Child Asthma and Child Eczema



Chronic Kidney Disease

Accessing Map of Medicine

All general practice clinicians, secondary care clinicians and other health professionals in Whanganui will be able to access electronic international, national and local clinical pathways on the Map of Medicine website.

To get registered with Map of Medicine to view care pathways please email Gerard Gregory at with the following details:

  • Name
  • Email address
  • Contact phone number
  • Role
  • Organisation
  • Department/Speciality

Once you are registered, you will receive an email with your username, password and a Map of Medicine User Guide Whanganui.

To access Map of Medicine go to:

Register Interest to be Involved

We are looking for passionate and motivated clinicians to join our pathway working groups.  These are short term roles that are anticipated to be for approximately 6-8 weeks per pathway with weekly 2 hour meetings.  If you are interested please contact Gerard Gregory on 06 348 0109 ext 738 or email:  Please indicate if you would like to be a Clinical Lead or a member of the working group, what pathway/s you are interested in and what discipline you represent (i.e. general practice, hospital, pharmacy, allied health etc.).

If you are interested in participating on a collaborative working group to help develop our local pathways for Whanganui, please complete the Expression of Interest form at the bottom of the page.

Roles and Responsibilities

Clinical Lead

Minimum knowledge, skills, and abilities required:

  • Extensive experience in relevant clinical setting.
  • Ability to provide a clear direction including initial actions.
  • Skilled in applying knowledge of environment resulting in sound and insightful strategic decisions.
  • Comprehensive knowledge of trends in clinical field.
  • Demonstrates skill in applying theory and trends to own practice.
  • Peers seek advice in relation to clinical skills/practice.
  • Practice demonstrates commitment to the provision of a quality service.

Principal duties and responsibilities:

  1. Provides active leadership, strategic direction and advice to facilitate the development, implementation and refinement of their collaborative clinical pathway
  2. Provides skilled clinical expertise into the development of drafts and final versions of the clinical pathway
  3. Ultimately responsible for the content of the final pathway
  4. Actively champions and provides professional direction and leadership
  5. Participates collectively and collaboratively with other clinical leaders and experts, to provide a clinical directorship function for the development of the pathway
  6. Ensure clinical risk is identified and appropriately managed
  7. Will actively participate in Collaborative Group meetings and adhere to the project timetable
  8. Will attend all Collaborative Group meetings
  9. Will come prepared to each Collaborative Group meeting

Working Group

Working group members are individuals with a strong knowledge of a particular area of expertise, who also have the ability to understand and respect diverse points of view.

Individual members nominated themselves to participate in the working group.

  1. Participate actively in group process to help ensure that progress is made, milestones are set, and the group operates in a fair manner
  2. Regularly attend meetings/sessions
  3. Review meeting minutes and participate in email discussions
  4. Working group members serve as conduits for two-way information exchange with their colleagues and/or peers to keep them informed about the process and the issues under discussion
  5. Accept and complete action items in a timely manner
  6. Share the responsibility of ensuring the success and the quality of the pathway
  7. Help ensure that the core rule of operation (rough consensus) is achieved

Map of medicine - Generic Collaborative Working Group EOI 24 Sept 2014

What's New

Expression of Interest - Prostate Cancer Pathway Development Working Group

As part of the Priority Cancer Pathways Project, the Collaborative Clinical Pathways team is currently inviting expressions of interest from clinicians with experience and an interest in Prostate Cancer. Clinical Pathways is a key enabler for ensuring General Practitioners can refer patients with a high suspicion of cancer directly to the most appropriate diagnostic and specialist service.

This collaborative sub-region (MidCentral, Whanganui, Hawke’s Bay) working group is being formed to draft a pathway to enhance the accuracy, early diagnosis and surveillance of Prostate Cancer in line with the Prostate Cancer Management and Referral Guidance document and the Faster Cancer Treatment (FCT) Programme. Background information on working group arrangements, and the relevant skills and experience required to participate is in the attached document.

To express your interest, please complete the EOI form by Wednesday 19th October 2016 and return via email to

EOI Sub-Region Cancer 2

Chronic kidney disease – Advanced form

A new Chronic Kidney Disease (CKD) advanced form has been implemented and can be found in Medtech32 under forms in Advanced Forms (SHIFT F3)/best practice. The Dashboard and BPAC tool are now available for activation and use at all practices. Ben McMenamin (Practice Facilitator) will be activating this new advanced form in all practices in the next four weeks.

*Don’t forget to use our nurse practitioner Albert Robertson (ph. 021 878 456, email: is available to support you in all your CKD management.

Advanced care plan – advanced form

There is a new Advanced Care Plan (ACP) advance form in Medtech32 that has been developed. This advanced form has not been implemented at practices yet but will be in the foreseeable future. There are also manual copies of the National ACP form that are still available and can be found from the WRHN front desk.

Dementia review

The Dementia pathway is currently under review. It has been live on Map of Medicine for the last 18 months. Changes made to the Dementia Suspected and Dementia Management pathway has been sent out for review and feedback. Feedback is also sought on the two advanced forms in Medtech32 called Dementia Suspected and Dementia Management. Please let us know if there are any improvements needed to be made on these two advanced forms. All feedback to

Fit for Surgery

This pathway is under development with feedback being sought from GP teams on how information is gained from patients on their lifestyle and what options are available in the community now to support individuals.

Hepatitis C

A regional Hepatitis C Pathway is completed and has been published in the central view. The Pathway will inform GP practices and other users on how to identify the at-risk groups, use targeted testing to diagnose people with chronic Hepatitis C and either refer them to the specialised service or, if they refuse, manage them in a primary care setting. It is expected that a single clinical pathway for Hepatitis C care should be implemented across all regions of New Zealand to provide consistent services which maximise the well being of all New Zealanders living with Hepatitis C. This will be reviewed locally and any local editions added.


The Cellulitis pathway has commenced in August 2016 and is currently under development.  Pre-work is being undertaken to identify best practice, model of care approach and options for workforce upskilling.


The Stroke Suspected pathway has been developed and is awaiting publication and launch alongside the Stroke Rehabilitation pathway.

A project is currently underway to review existing hospital provision of community rehabilitation services including contracts. The Stroke Rehabilitation Pathway development will align with this review and will focus on how coordinated community stroke rehabilitation will be provided in the future. The community rehabilitation project has identified service provision gaps particularly in the Allied Health domain. A central triaging referral system has been established to streamline complex discharges. Alongside this access to community physiotherapy and occupational therapy are being streamlined. Referrals and responses are being monitored to identify service improvement opportunities. This has been reported in the quarterly MOH report. Further collaboration is required between secondary care services and community agencies.

The stroke discharge project is particularly streamlining stroke prognostic indicators and discharge destination planning process. The expectation is that in September the project reports will be completed for both projects which can then inform the completion of the community rehabilitation map leading to publication in October and launch in November 2016.


The following pathways have been localised for Whanganui and published on Map of Medicine:

  1. Child Asthma
    • Asthma in Children - Chronic Management
    • Asthma in Children - Acute Management
  2. Child Eczema
    • Eczema in Children
  3. Dementia
    • Dementia - Assessment (Has been reviewed and republished)
    • Dementia - Management (Has been reviewed and republished)
  4. Assessment of Acute Chest Pain
  5. Acute Coronary Syndrome (ACS)
  6. Atrial Fibrillation (AF): Suspected & Ongoing Management in General Practice
  7. Advance Care Planning (ACP)
  8. Chronic Kidney Disease (CKD)
    • CKD Management
    • Management of Increased Creatinine
  9. Colorectal Cancer
  10. Deep Vein Thrombosis (DVT)
  11. Falls in Older People
  12. Lung Cancer
  13. Osteoporosis and Fragility Fracture
  14. Stroke and Transient Ischaemic Attack
    • Immediate Management of Ischaemic Stroke
    • Immediate Management of Intracerebral Haemorrhage
    • On-going Management of Ischaemic Stroke
    • TIA and Secondary Prevention of Stroke
  15. Breast Cancer

The following pathways are currently under development:

  • Stroke
    • Stroke or Transient Ischaemic Attack (TIA) - Suspected
    • Stroke Rehabilitation - In-patient and Community
  • Chronic Obstructive Pulmonary Disease (COPD)
    • COPD Suspected
    • COPD Stable Management
    • COPD Acute Exacerbation
  • Mental Health
  • Cellulitis
  • Hepatitis C
  • Heart Failure
    • Heart Failure - Suspected
    • Heart Failure - Management
    • Heart Failure - Acute

The following pathways are to be developed:

  • Smoking Cessation
  • First Trimester for Pregnant Women - Early Booking During Pregnancy
  • End of Life Care
  • Prostate Cancer
  • Orthopaedic
  • Diabetes

Map of Medicine

Whanganui Regional Health Network (WRHN) and Whanganui District Health Board (WDHB) have commenced the Collaborative Clinical Pathways (CCP) Programme within the district.  A Collaborative Clinical Pathways Leadership Team has been set up to implement this initiative and will use Map of Medicine (MoM) as the pathway development tool.

mom NZ logo cropped

The Combined Clinical Directors have endorsed the adoption of MoM (currently being used by MidCentral's Collaborative Clinical Pathways Team) as a means of improving communication and referral pathways between providers, and standardising clinical practice thereby enhancing patient health and wellbeing.  The use of MoM by both MidCentral and Whanganui is being seen as an opportunity to facilitate regional work through the Regional Alliance Framework.

What is Map of Medicine?

Map of Medicine (MoM) is a UK based software system which houses a collection of approximately 400 clinical pathways based on existing evidence and international guidelines.  There are also a further 1500 "localised" pathways available to view. These pathways are accessible to authorised users via the internet, and can be used as:

  • A rapidly accessible check of best practice, most likely to be used by frontline clinicians;
  • A tool to assist in planning and development of health services across the district, using evidence-based clinical pathways.

Why have we adopted Collaborative Clinical Pathways?

Benefits of using Collaborative Clinical Pathways include:

  • Seamless referral of patients across general practice and hospital care ensuring appropriate screening, diagnostics, referrals, treatment and follow-up
  • Guaranteed acceptance of referrals if pathway is followed by clinician
  • Priority of access to diagnostics if pathways is followed by clinician
  • Electronic referral forms; self-populating referral forms for MedTech users
  • Using best practice guidelines
  • All information is found in one place and using updated guidelines and best practice - efficient use of time
  • One agreed tool for clinicians in hospital and general practice to use - enhanced partnerships and collaboration across services
  • Improved patient outcomes through seamless care across general practice and hospital care


The sponsor for the CCP programme is the Alliance Leadership Team (ALT).

The CCP programme has been endorsed as a WDHB/WRHN key priority in the annual plan and is being led by the CCP Leadership Team.  The membership of the team is made up of the following members:

  • Julie Nitschke (CD WRHN)
  • Rick Nicholson (CD WRHN)
  • Jevada Haitana (Associate Director of Nursing WDHB)
  • Tom Thompson (CD WDHB)
  • Gerard Gregory (Pathways Facilitator)

For more information, please read the CCP Whanganui Information flyer below.

CCP Whanganui Information FINAL