About The Role:
This position reports to the Manager Quality, Resident Safety and Research, and is responsible to provide consultation and leadership in the identification and integration of best practice processes across continuing care services and programs; including leading and supporting continuous quality improvement in collaboration with Bethany site leadership teams.
This position will research best practice processes, ensuring continuous alignment of Bethany policy and compliance with national, provincial standards, policy and guidelines. The Quality Practice Leader monitors and evaluates opportunities to improve care quality and enhance safety across sites and establishes relationships and communities of practice that support Bethany’s Mission and Values. The incumbent will maximize benefits achieved from Bethany’s Integrated Quality Management System to ensure and support best practice processes are implemented and quality and safety risks are monitored and addressed through continuous quality improvement as evidenced by resident, family and staff experiences.
What You Will Do:
1. Clinical Documentation Review and Chart Audit Responsibilities
- Conduct structured reviews of resident charts across long-term care sites using Bethany-approved tools, audit criteria, and master chart expectations.
- Review both electronic and paper-based chart components to assess completeness, organization, timeliness, consistency, and accessibility of required documentation.
- Assess alignment between current chart practices and Bethany’s master chart policy, chart thinning expectations, and clinical documentation standards.
- Review selected documentation areas such as care plans, assessments, progress notes, physician orders, MAR documentation, PRN effectiveness documentation, wound and skin documentation, falls documentation, restraint documentation where applicable, pain assessment documentation, and resident / family conference documentation.
- Identify missing, misplaced, incomplete, outdated, duplicate, or inconsistent documentation.
- Distinguish between site-specific filing / organization issues, documentation-practice issues, and broader system or policy issues requiring Quality team follow-up.
Performance Measures
- Chart reviews are completed using approved criteria and documented in a consistent format.
- Documentation gaps are clearly described, evidence-informed, and linked to the relevant chart standard, policy expectation, audit criterion, or regulatory requirement where applicable.
- Findings are practical, specific, and usable by site leaders and the Quality team.
- Reviews identify both immediate resident-record risks and recurring system-level patterns.
2. Master Chart Policy and Process Alignment Responsibilities
- Review Bethany’s master chart and related health record policies, supporting documents, forms, and tools.
- Compare policy expectations with actual chart organization and documentation practices at selected long-term care sites.
- Identify where current practice does not align with policy or where policy language, process guidance, or supporting tools require clarification.
- Recommend practical changes to improve consistency in chart structure, active chart content, thinning practices, filing practices, and documentation workflows.
- Support Quality leadership in identifying whether issues are best addressed through policy clarification, workflow redesign, education, audit follow-up, or site-level action.
Performance Measures
- Master chart alignment issues are clearly categorized by site-specific issue, cross-site issue, policy issue, or workflow issue.
- Recommendations are realistic for long-term care operations and do not create unnecessary documentation burden.
- Findings support a more consistent organizational approach to resident chart maintenance and documentation review.
3. Site Engagement and Remediation Support Responsibilities
- Work respectfully and constructively with Site Administrators, Care Services Managers, clerical staff, Quality Practice Leaders, and other relevant team members.
- Share findings in a manner that supports learning, standardization, and corrective action.
- Assist sites and Quality team members to identify practical remediation steps for chart organization and documentation gaps.
- Provide coaching or clarification to designated leaders and staff on chart expectations, documentation requirements, and audit findings where appropriate.
- Escalate significant or recurring documentation risks to the Director, Quality and Resident Safety, or designate.
Performance Measures
- Site feedback is clear, respectful, and actionable.
- Remediation recommendations identify priority, owner, suggested action, and follow-up requirement where possible.
- Serious documentation concerns are escalated promptly.
- The role supports accountability without creating confusion about site management responsibilities.
4. Cross-Site Standardization and Quality Improvement Responsibilities
- Compare documentation and chart practices across sites to identify common issues, useful local practices, and opportunities for standardization.
- Contribute to a consistent approach for future chart audits, documentation reviews, and follow-up workflows.
- Support the Quality team in identifying patterns that may inform policy review, education planning, audit tool refinement, or integrated quality management processes.
- Identify opportunities to reduce duplication, improve chart usability, and strengthen continuity of care documentation.
Performance Measures
- Common themes and cross-site patterns are identified and summarized.
- Recommendations support consistent practice across Bethany’s long-term care sites.
- Findings contribute to Quality team planning and ongoing compliance monitoring.
- Audit and review outputs are suitable for use in quality improvement tracking and accreditation readiness.
5. Reporting and Deliverables Responsibilities
- Prepare site-level chart review summaries, including key findings, priority risks, recommended actions, and follow-up considerations.
- Maintain organized working records of review activity, findings, and supporting observations.
- Provide regular progress updates to the Director, Quality and Resident Safety, or designate.
- Prepare a final summary report that identifies:
- scope of review completed,
- common documentation and chart organization gaps,
- site-specific findings where appropriate,
- policy or workflow issues,
- immediate corrective priorities,
- medium-term recommendations,
- suggested future monitoring approach.
Performance Measures
- Reports are concise, accurate, well organized, and submitted in the agreed format.
- Final recommendations distinguish between short-term clean-up, operational practice change, policy clarification, and longer-term system improvement.
- Deliverables can be used by Quality leadership for follow-up planning and decision-making
Qualifications
Education & Professional Designation
- Current registration in good standing as a Registered Nurse in Alberta.
- Bachelor of Nursing preferred.
- Additional education in quality improvement, clinical documentation, health records, compliance, or continuing care is an asset.
Experience
- Minimum 5 years of registered nursing experience, preferably in long-term care, continuing care, seniors care, or a related regulated healthcare environment.
- Experience with clinical documentation review, chart audits, quality assurance, accreditation preparation, compliance monitoring, practice review, or policy implementation.
- Experience working with both paper-based and electronic resident / client health records.
- Experience supporting practice standardization across multiple sites is an asset..
Additional skills
- Strong understanding of long-term care documentation expectations, interdisciplinary care planning, resident assessment, progress notes, and continuity-of-care documentation.
- Ability to interpret policy, audit tools, clinical standards, and regulatory requirements and apply them to operational practice.
- Strong clinical judgement, attention to detail, and ability to identify documentation risk.
- Strong written communication skills, including ability to prepare clear findings and practical recommendations.
- Ability to work independently while maintaining alignment with Quality leadership.
- Skilled in respectful consultation, coaching, and collaboration with site-based teams.
- Proficiency with Microsoft 365 applications, including Word, Excel, Outlook, and Teams.
Position Information:
Location:
Calgary, Alberta
Site:
Bethany Corporate Office
Site Address:
100, 2915 – 26th Avenue SE, Calgary AB, T2B 2W6
Classification:
Quality Practice Leader (CDR-CP33-027)
FTE:
0.60
Non- Union/Union:
Department/Unit:
Quality Care & Service Development - CMS
Time Type:
Part time
Position Type:
Temporary (Fixed Term)
Shift & Hours of Work:
Days (0800-1615)
Shift per Cycle:
Monday to Friday
Position Start Date:
2026-07-06
Position End Date:
2027-03-31
All applicants are thanked for their interest. Only those selected to move forward will be contacted.
Bethany Care Society is an equal opportunity employer.
Successful candidates will be required to obtain a Criminal Background Check and provide proof of all mandatory immunizations.
Bethany Care Society complies with the Personal Information Protection and Electronic Documents Act (PIPEDA). By forwarding your resume to Bethany you are consenting to the collection and use of your personal information for this job competition. Your information will be kept strictly confidential.
