The Just Culture Community

Curated by Outcome Engenuity, LLC

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.

Whack-a-MoleIn 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 and the special Outcome Engenuity Champions Forum at

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.




David Denton

Client Relations Specialist/SQA/Helpdesk Support

David Denton supports our clients through implementations and sales, and he plays a key role in our software development projects. He seeks to ensure that our clients have the best possible experience.



Dave Nakata

Chief Operations Officer

The bulk of Dave’s experience comes from the aviation industry, where he helped pioneer maintenance, reliability and human factors processes. He is now the COO of Outcome Engenuity.



David Marx

Chief Executive Officer

David is the founder and CEO of Outcome Engenuity.


David Van Rycke

Client Relations Specialist

David Van Rycke supports our clients through implementations and sales. He seeks to ensure that our clients have the best possible experience.




Dave Wise

Media and Outreach

Dave helps in our media developments like video,  graphics, websites and marketing materials .


Ellen J. McDermott


Ellen McDermott is one of our advisors. As an Army veteran and a J.D., Ellen now turns her attention to building tools and helping our clients learn the five skills.



Janii Bouziden

Client Relations Specialist

Janii Bouziden supports our clients through implementations and sales. She seeks to ensure that our clients have the best possible experience.



Jared Jared Smith

I.T. / Software Developer

Jared is our general purpose software developer and primary developer for the upcoming software product — Electronic Algorithm. His primary focus is to create the best possible product to aide in the promotion of a Just Culture.

Jerry Allen-advisor Jerry Allen


Jerry Allen is an advisor that comes to OE with three decades of human factors experience in high reliability organizations, including co-delivery of the first Just Culture seminars in high-reliability organizations with David Marx .  Jerry will be helping our clients learn the five skills and assist them on their OE Just Culture journey.


John Westphal


John Westphal is an advisor that has been with Outcome Engenuity since its inception. John builds tools and helps our clients learn the five skills.


Matt Bassuk

Instructional System Designer

Matt Bassuk is our Instructional System Designer. If it’s about providing support for any of our advisors and trainers or designing our online instructional materials, Matt’s the guy.


Ross Ethridge

Network Administrator/Designer

Ross’s background is in Network Security and OpenSource computing projects.

He has spent the majority of his career working with the Department of Defense and building Multiplayer Online Video Games.


Tom Nguyen

Finance Manager/Human Resource Coordinator

Tom Nguyen is responsible for managing the day to day Finance of the Organization as well as coordinating any Human Resources related request.