Performance measurement and accountability are the most frequently encountered concepts across healthcare systems, although the tools used to put these concepts into practice vary. The aim of the present article was to discuss the tools (e.g., indicators) and user expectations (e.g., quality versus performance) of these tools in fulfilling healthcare's accountability mandate. In particular, the developments within the Spanish health system are discussed to illustrate how Spain has addressed, in a stepwise manner, the determinants of a national accountability model. Finally, a multinational project, The Maryland Quality Indicator Project, is presented as a popular framework for measuring performance.