ISMP Presents Lifetime Achievement Award to David Marx

David Marx Lifetime Achievement Award

David Marx Lifetime Achievement AwardAt its Annual Cheers Awards Dinner on December 6, 2016, ISMP presented a Lifetime Achievement Award to David Marx, CEO of Outcome Engenuity, for his ongoing contributions to healthcare patient safety initiatives and his significant impact on safe medication practices.  In a career spanning three decades, ISMP recognized David Marx as a true pioneer in the safety world.  Through the integration of systems engineering, human factors, and the law, David has built working environments that are more resistant to human error and changed the paradigm for how we manage individuals involved in medication errors and other types of failed outcomes.

David has authored a Patient Safety Guide for the National Institutes of Health, advised the US Agency for Healthcare Research and Quality on safety issues, created the Five Rules of Causation for the FAA, and led an external team benchmarking NASA’s Space Shuttle processing. Additionally, he has authored two books on workplace accountability: Whack-a-Mole: The Price We Pay For Expecting Perfection and Dave’s Subs: A Novel Story About Workplace Accountability. In 2005, ISMP awarded David an individual Cheers Award for his development of the Just Culture model. Incorporating lessons learned from aviation, aerospace, transportation, healthcare and other high-risk industries, David continues his efforts to help workplaces achieve highly reliable outcomes through his development of human factors risk modeling methods and as the father of the Just Culture accountability model.

imsp_cheers_awardOutcome Engenuity is honored to be recognized by Michael Cohen, founder, and CEO of ISMP, and his lifetime achievements of making medication practice safer for all through his tireless work at ISMP.

Outcome Engenuity to Exhibit at the AONE 2016 Annual Meeting

aone2016-logoAre you and your colleagues planning to join the thousands of nursing leaders at the American Organization of Nursing Executives (AONE) Annual Meeting 2016? We are. Outcome Engenuity (Oe) is set to be a part of the Exhibition at the AONE 2016 Annual Meeting. Visit our exhibition booth for more on David Marx's latest book, Dave's Subs: A Novel Story about Workplace Accountability. We will have copies on hand to give away. We will also be available for more information on Just Culture training and products.

The AONE 2016 Annual Meeting is scheduled to run March 30 - April 2, 2016, with the Exhibition being from March 31 - April 1. For more information, visit:

We hope to see you there!

David Marx presents as core speaker at ISQua International Conference

IsquaDoha2015Just in October, healthcare leaders from across the world gathered together in Doha, Qatar at the International Society for Quality in Health Care (ISQua) International Conference to improve patient safety through the sharing and garnering of innovations and promoting new ideas.

As an international conference devoted to the improvement of patient safety, ISQua sought out the world’s chief healthcare experts to facilitate learning through presenting on their areas of expertise. Among the sought-after experts was Outcome Engenuity CEO and father of Just Culture, David Marx — considering his extensive experience in pioneering, developing and implementing Just Culture principles in healthcare — as well as various other industries across the globe.

A study in the Journal of Patient Safety from 2014 reported that more than 400,000 patients’ die every year from preventable medical harm. Bearing these numbers in mind, health care organizations are increasingly longing for justice and accountability within their complex systems to better manage employee behavior, improve learning systems and produce better outcomes (and so improve patient safety) within their organization. Consequently, this is a matter many health care leaders long to dive in to, making Marx a prime candidate as a core speaker at the ISQua International Conference.

Recognizing that hospitals, nursing facilities and ambulatory care facilities all face the task of building a stronger culture of accountability within their organizations, Marx framed his presentation around the movement to create a more accountable culture within the workplace. Marx also discussed the necessity of building a strong reporting and investigative culture, as well as the task of managing behavioral choices, providing many insights for organizations striving to accomplish this task:

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Millitary hospitals looking to Just Culture for the answer?


Mass. hospitals show how to fix military medical care




Courtesy Boston Globe / Associated press
Army Surgeon General Lieutenant General Patricia Horoho speaks about military health care at the Pentagon in October.

Military hospitals charged with one of the country’s most important missions — serving active duty personnel — are roiled by dysfunction. As reported by The New York Times over the last several months, military hospitals suffer from chronic lapses in patient care and safety. Outgoing Secretary of Defense Chuck Hagel addressed the problem in October, when he ordered the military health system to reassess and revamp its procedures. But it might take nothing less than an act of Congress to change practices and procedures that are ingrained in military culture.

The command and control system that works well on the battlefield puts the military health care system out of touch with most modern medical institutions, where questioning of the system is a crucial component of everyday practice. The latest Times report described a system in which physicians and nurses who point out lapses in care are transferred or passed over for promotion, compromising patient safety and quality of care.

The Times report found that two areas of treatment in the military health system were particularly vulnerable — maternity care and surgery. A Pentagon review of the military’s hospitals found a systemwide problem: a reluctance by medical workers to identify problems, for fear of reprisal.

The reluctance to report errors is understandable. But in a medical setting, decision-making can literally be a matter of life or death — which is why civilian hospitals and medical centers have been working hard over the past 20 years to encourage “blame-free” reporting.

At three of Boston’s biggest hospitals, various high-tech systems for reporting errors are in place. Such a system is sometimes called a culture of safety or, after one model that was developed in the late 1990s, “just culture.” Massachusetts General Hospital, Brigham & Women’s, and Beth Israel Deaconess Medical Center all follow some version of the “just culture” model for reporting errors. Anyone from a janitor to a nurse to a surgeon is encouraged to report errors in a non-punitive environment, and there are active campaigns to encourage reporting. The principals of “just culture” defer blame from an individual to the system as a whole.

To gather these reports, hospitals establish websites available to all employees. The reports are vetted and analyzed, with protocols for followup. In some cases, individuals are held accountable for a decision that’s seen as reckless. But for the most part, “just culture,” says Karen Fiumara, director of patient safety at Brigham & Women’s, describes “a culture of trust and shared accountability.”

Such a reporting system sounds like common sense. But “just culture” is antithetical to the military hospital system for a very basic reason: chain of command. As hospital administrators point out, the “just culture model” won’t work unless leadership insists on it. The assistant secretary of defense for health affairs, Dr. John Woodson, an Obama appointee, has made strong statements about reforming the system, but his power is restricted to making policy recommendations. He cannot give orders to military commanders, and they’re the ones charged with running military hospitals.

One person who does have responsibility for change is the Army Surgeon General, Lieutenant General Patricia Horoho. Horoho has issued a statement demanding transparency regarding patient safety, and she has won praise from at least one member of a civilian agency in charge of inspecting and accrediting hospitals. “I applaud the way she’s handled the situation,” Dr. Ronald M. Wyatt said in an interview, adding that hers are the kind of actions “that resonate throughout the system.”

But the system, as it’s structured now, is working against Horoho, a decorated Army nurse. For one, commanders rotate out of assignments approximately every three years. And there’s no guarantee that Horoho herself, who has been Army surgeon general since 2011, will remain in her job much longer. “Imagine if the CEO at a civilian hospital changed every three or four years,” said Wyatt.

The problems in leadership stability are also compounded by the fact that the military hospital system is divided into three units for each branch of the armed services. What’s more, the system — whose primary mission is to train medical personnel for combat— is under strain after 12 years of war.

Clearly a system overhaul is required, one that at the very least involves the implementation of a stable leadership program in which just culture protocols are implemented. At best, the system would be streamlined, unifying all the branches of the military into one hospital system. Military service men and women put their lives at risk regularly overseas. They and their families shouldn’t be put in harm’s way when they seek medical help at home.

Healthcare Associations Can Offer Deep Discounts To It’s Members – Here’s How

Leaders around the world are supporting Just Culture initiatives

By being a Just Culture Connector, you can support your members in their initiatives and lead them in their journey by any of these three options:

  • Host a course for your hospitals and get 5 free seats
  • Promote a course with an exclusive member discount code for registrants
  • Support an OE Just Culture statewide initiative and offer discount Enterprise Licensing for all of your hospitals

Download “Whack-a-Mole” Digital Copy

David Marx says, "Give it away...". Whack-a-Mole: The Price We Pay For Expecting Perfection, by David Marx is now offered in a digital copy.



Whack-a-Mole: The Price We Pay For Expecting Perfection explores the role of human error in society, from aviation and healthcare, to driving and parenting—and where accountability rests for those errors, especially when they take the life of another. David Marx argues that regulatory and human resource prohibitions, along with the criminal prosecution of human error, have been counter-productive to helping society deal with the risks and consequences of human fallibility. Marx advocates a different approach to addressing our shared fallibility.

Scroll down to get your copy (digital download) of Whack-a-Mole: The Price We Pay For Expecting Perfection. by David Marx, JD, CEO of Outcome Engenuity and father of Just Culture and engineer of the The Just Culture Algorithm™ 

-Learn More About Just Culture-  -Just Culture Training Events-  -Event Investigation/Root Cause Analysis-

Outcome Engenuity’s Just Culture Certification Courses for 2014

About This Course:



Individuals interested in the Just Culture Model to improve their leadership effectiveness.

If you are an organization interested in a systemic implementation of Just Culture, we recommend a team from each section of your organization capable of guiding your organization in the training and implementation of the Five Skills Model; in particular, leaders from operations, safety/risk/quality, and HR. This course is open to professionals from all industries.

Note: This is now a 3 day course only.


Just Culture Certification Course Overview:

This is the Just Culture flagship course. It is designed to improve leadership effectiveness through use of the Just Culture model. As a society, we struggle with the question of how to hold human beings accountable when they fail to live up to our expectations or when a significant event occurs. This is true for our justice systems, for our organizations and for us as individual leaders. This course provides the most comprehensive instruction available in the Five Skills Model for achieving better outcomes:

  • Identifying Values and Setting Expectations
  • Improving System Design
  • Managing Behavioral Choices
  • Building and Utilizing Robust Learning Systems
  • Ensuring Justice and Accountability – The Just Culture Algorithm

As a Certified Just Culture Champion you are versed in the history of Just Culture, able to integrate the Five Skills Model into your leadership practices, and highly proficient in the correct application of the Just Culture Algorithm. We discuss how a Just Culture helps in designing systems that anticipate human error, at-risk behavior, and reckless behavior. The Just Culture Algorithm is the premier tool used to achieve both justice and accountability across industries worldwide. During the course, participants will receive hands-on practice and examine how this tool integrates the law with key principles of socio-technical engineering.

Materials Provided In The Course:

  • Just Culture Certification CourseThe Just Culture Algorithm v3.2
  • Event Investigation Toolkit and Online Training
  • Coaching & Mentoring Action Guide and Online Training
  • Just Culture for Managers Workbook and Online Training
  • The Proposition
  • The Final Check Toolkit


You will be prepared with online training, display your proficiency with an exam, and review your exam with a Just Culture Advisor to fine tune any areas you may be struggling with and discuss any concerns you may have about implementing Just Culture in your organization. Upon certification, you will also gain membership in a community of more than 1,500 Champions worldwide who have demonstrated in-depth Just Culture proficiency and competency in the Just Culture Algorithm™. Access to the Just Culture Certified Champion Network provides you with ongoing resources and learning support tools to sustain your personal and professional development, and provides a forum for sharing of organizational experiences and Just Culture best practices.



Free OnDemand Webinar
Just Culture Champions / Creating That Internal Resources - Presented by John Westphal

Thank You.

The Future of Just Culture

David Marx, Outcome Engenuity CEO and the father of Just Culture, explains where Just Culture started and where it's going next. Marx has developed the Just Culture Algorithm and ST-PRA, and refined many of their concepts into actionable improvements when applied to organizational safety and the management of human behaviors.

The world is ready for this next breakthrough and you can be a part of it.

 Just Culture is now poised to grow into it's full state of maturity. It has advanced from addressing the complicated design of safer systems and behavioral management and event management concepts into total performance management for employees of all levels. It is now a complete organizational solution for performance management of every employee in every position in any department. Working with individual events is an important part of the Just Culture journey, but how each of those events fits into the employee’s body of work is equally vital. This course assists managers in re-conceptualizing event management in the larger context of employee performance and is intended to prepare managers and leaders to extend the principles of Just Culture to the entire performance management process.

Outcome Engenuity is pleased to announce latest advancement to Just Culture in its new course, “Performance Management – the Just Culture Way,”

This video will prove valuable to a better understanding of where Just Culture has been and where it's going next. We highly recommend reading the attached whitepaper and pass it along. Just Culture, it's the right thing to do. Thank you for joining us.

Download the whitepaper here.