Therefore, collectivism can be considered the second main factor after that of religion in influencing Saudi culture.
On the other hand, one of the cultural issues influencing healthcare in Saudi Arabia is consanguineous marriages. These societies prefer consanguineous marriages for various reasons such as to strengthen family relationships or to avoid financial assets or property falling into the hands of individuals outside the family (Bittles, 2001). Regarding healthcare, according to Al- Abdulkareem and Ballal (1998), consanguineous marriages have been found to be one of the causes of certain inherited blood diseases among Saudis. In 2003, the Saudi government therefore introduced a pre-marriage test to reduce the rate of such diseases. However, a study by Alsulaiman and Hewison (2006) on attitudes to the pre-natal and pre-implantation diagnosis of Saudi parents at genetic risk showed that, out of 30 couples asked, only 50% would accept such a test.
In KSA, modern healthcare system and quality management did not exist until 1926. Up until then, health services had been provided by individuals not governmental authority. Healthcare and quality have organised through several stages to reach present day status. However, quality management started to appear in the public and private healthcare sectors, by many workers attracted to the idea of Total Quality Management (TQM).
Dale (2007) argues that shifting TQM from the manufacturing industry to the health sector is difficult for a number of reasons: the managerial environment differs from other sectors, consumers in healthcare are different as they use the service as patients, the nature of failure, where few errors are able to be fixed and the complexity of the workforce in the health sector. All these reasons make the implementation of JCI accreditation standards in TQM or continuous quality improvement a challenging

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