HALIFAX -- Hospitals in Cape Breton should be in compliance with all of the provincial auditor general's recommendations on infection control by the end of the year, the CEO of that region's health board said Wednesday.

Dianne Calvert Simms, CEO of the Cape Breton District Health Authority, told the Nova Scotia legislature's public accounts committee that 14 of 20 recommendations have been met and the remainder are largely administrative that will soon be implemented.

The recommendations were issued by auditor general Jacques Lapointe following deadly outbreaks last year of C. difficile at the Cape Breton Regional Hospital and Glace Bay Hospital. Four patients died as a direct cause of the infection in the initial outbreak, while another person died in a subsequent case.

In his report, Lapointe said the outbreaks may have been avoided if staff had used proper cleaning methods to prevent the spread of infections.

Calvert Simms said Wednesday that the health board is continuing to improve hospital and staff hygiene along with sterilization procedures. But she said changing the culture so that practices like hand washing becomes second nature continues to be a challenge.

"We need public participation and support in not just hand hygiene but in making sure that they have asked (health) providers whether they have washed their hands," Calvert Simms said after speaking with the committee.

Calvert Simms said an electronic hand hygiene database is helping to track staff hygiene compliance and the board is continuing to examine whether to switch cleaning products used in hospitals.

She said three additional staff and a manager dedicated to infection control have also been hired since the outbreak of the bacteria.

Deputy health minister Kevin McNamara said his department continues to monitor the health authority's progress. He said Health Department staff made a surprise visit to the hospitals in the summer and reported significant improvements in hygiene practices.

"This was done specifically to Cape Breton because we wanted to ensure public confidence that they were providing good care," McNamara said.