About Outcome Engenuity

 We are the curators of The Just Culture Community.

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 Just Culture journey.

Who We AreWhat We DoHow We Do ItWhy We Do It

OE-site-image-190x1901Outcome 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.


Daves Subs web-cropped

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.







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 it is our first class training and tools developed to make the best outcomes a possibility for all. Along the way we provide a vast support system through our advisors, client relations support, online and live training, workshops, tools and community websites at www.outcome-eng.com and the special Outcome Engenuity Champions Forum at social.justculture.org.

We offer a simple proposition about the design of the world around us. The proposition is this:

Framed by the right systems of learning, the right systems of justice, we can design systems and help humans make the choices in those systems that produce better outcomes, at the individual, local, and societal level.David Marx

Justice in the workplaceAround this proposition, we present a set of design laws that influence our ability to create the societal outcomes we desire. They are the laws you must take into consideration when you attempt to design social systems, whether you are a parent, a manager, a CEO, or a lawmaker.

As a company, we have committed ourselves to this proposition and its accompanying design laws. We build tools and offer assistance to those who are committed to building a better world.

Design for LifeWe 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.