We are often thought of as "The Just Culture Community" as if it were our operating business name. We take that as a compliment. Yet we are honored to be the team effectively leading and curating the worldwide community of organizations along the journey of improving its outcomes by improving its culture, learning systems, design, and reliability.

Who We AreWhat We DoWhy We Do It

Outcome Engenuity, LLC was founded in 1997 by CEO David Marx. The firm originally addressed safety issues and human factors in aviation and offered expertise in post-event investigation and analysis. With the unique combination of systems engineering, human factors, and the law, David adopted and expanded the concepts of ‘Just Culture’ to help improve the management of human error.

It wasn’t long before David branched out to several other high-consequence industries. Spurred by the Institute of Medicine’s 1999 seminal study, To Err Is Human: Building a Safer Health System, and recognizing the need for a Just Culture approach, David began focusing on healthcare. The study showed that 98,000 people died annually from medical errors – a number which has only increased in the intervening years.

In 2003, Marx wrote "Patient Safety and the ‘Just Culture’: A Primer for Health Care Executives" for the National Institutes of Health.


Released November 2015 Dave's Subs: A Novel Story About Workplace Accountability is David Marx's latest book. It’s a business book.   It’s an instructional tale for  every CEO, director or manager who’s had to learn how to hold her employee accountable, to learn how to create a strong organizational culture.  It’s even a story for  the everyday employee — giving them a glimpse of a truly aspirational workplace culture.





Whack-a-Mole: The Price We Pay for Expecting Perfection

In 2009, Marx published Whack-a-Mole: The Price We Pay For Expecting Perfection, an easy-to-read explanation of the Just Culture and how we can benefit from its ideas in our everyday lives.



For more than two decades now, the company has advanced the concept of Just Culture and its role in the design of effective socio-technical systems.

We have integrated systems engineering, human factors science, and even the law into unique strategies that are among the best in the world. We’ve created some of the most complex socio-technical risk models the world has ever seen, taught industries how to investigate events, and we’ve pioneered modern notions of values-supportive justice and learning (Just Culture).

We are a concept company. We are a product company. We are a service company. We are here to help high consequence industries, from aviation and healthcare to spaceflight and nuclear power, to improve safety. We help our clients produce better outcomes – whatever their mission, and whatever values they strive to protect.

For NASA, it was our event investigation skills, and our approaches for prospective socio-technical risk modeling that fit their needs.

For most hospitals and airlines, it is our Just Culture suite of tools that fit their need to change organizational culture.

For the Federal Aviation Administration, it was helping air traffic controllers find a reasonable balance between learning and accountability.

For the National Patient Safety Foundation (NPSF) and the Flight Safety Foundation (FSF), it is an ongoing outreach to improve safety.


For the South Carolina Hospital Association, it was simply a desire to help in any way we could to reduce the rate of adverse events in one particular area. Check out more information about how we accomplished this with The Final Check.

Helping you produce better outcomes – that is our desire.


For every organization and business worldwide, our first-class live and online training and software applications are designed to achieve the best outcomes possible. Along the way, we provide a vast support system of advisors, client relations specialists, and a dedicated Champions Forum.

We have come to the conclusion that the outcomes we create across society are outcomes of our choosing – whether by acts of commission or acts of omission. For most problems, it is not that we cannot find an elusive ‘cure.’ Rather, it generally comes down to the basic problem presented to the economist: how do we steward limited resources for the greater collective good? Perfection or utopia, the complete elimination of harm, is not in our future. That said, we can be better stewards of our resources today; we can indeed produce better outcomes.

We want to celebrate those who get it right. Most importantly, we want to bring focus to those places in the world where we can make a difference.